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Henry Williams Application Package Page 1 of 6 F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx Updated: June 2020 BOARD AND COMMITTEE APPLICATION Last Name First Name Middle Initial Home Address City State Zip Code Cellular Telephone Work Telephone Home Telephone Email address Business Name Occupation Business Address City State Zip Code Please list your preferences in order of ranking: [1] first choice, [2] second choice, and [3] third choice. Please note that only three (3) choices will be observed by the Office of the City Clerk. Ad Hoc Anti-Bullying Task Force Health Advisory Committee Normandy Shores Local Government Neighborhood Improvement District Advisory Council Affordable Housing Advisory Committee Health Facilities Authority Board Parks and Recreational Facilities Board Animal Welfare Committee Hispanic Affairs Committee Personnel Board Art in Public Places Committee Historic Preservation Board  Planning Board Audit Committee Housing Authority Police/Citizens Relations Committee Board of Adjustment Human Rights Committee Production Industry Council Budget Advisory Committee LGBTQ Advisory Committee Program for Public Information Committee Committee for Quality Education in Miami Beach Marine & Waterfront Protection Authority Senior Affairs Committee Committee on the Homeless Mayor’s 41st Street Committee Sustainability Committee Convention Center Advisory Board Mayor’s General Obligation Bond Oversight Committee Transportation, Parking, and Bicycle- Pedestrian Facilities Committee Cultural Arts Council Mayor’s Panel on Ocean Drive Visitor and Convention Authority Design Review Board Miami Beach Commission for Women Youth Commission Disability Access Committee Next Generation Council 1. _____________________________________ 2. _____________________________________ 3. _____________________________________ Professional License Type of Professional License License Number State of Issuance License Issuance Date License Expiration Date Note: If you are seeking appointment to a professional seat (e.g. attorney, architect, etc.), you must attach a copy of your currently effective corresponding professional license. Page 2 of 6 F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx Updated: June 2020 ● I am applying for an appointment because I have special abilities , knowledge, and experience. Please list below: AFFILIATION WITH THE CITY OF MIAMI BEACH Pursuant to City Code section 2-22(4) a, b, and c: Members of Agencies, Boards, and Committees shall be affiliated with the City. This requirement shall be fulfilled in the following ways: a. Resident of the City for a minimum of six months: Yes or No ● I am a resident of: South Beach Middle Beach North Beach Or b. Demonstrates an ownership interest (for a minimum of six months) in a business established in the City (for a minimum of six months): Yes or No “Ownership Interest” shall mean the ownership of ten percent (10%) or more (including the ownership of 10% or more of the outstanding capital stock) in a business. “Business” shall mean any sole proprietorship, sponsorship, corporation, limited liability company, or other entity or business association. Or c. Full-time employee of such a business (for a minimum of six months); and I am based in an office or other location of the business that is physically located in Miami Beach (for a minimum of six months): Yes or No Notwithstanding the requirements set forth herein, the qualified full-time employee of a business must be approved by a 4/7th vote of the Mayor and City Commission. NOTE: Members of Agencies, Boards, and Committees shall be required to demonstrate compliance with the City affiliation requirements of sections 2-22 (4) a and b of the Miami Beach City Code by executing an affidavit, stipulating that they have met either (or both) of said affiliation requiremen ts. The original affidavit shall be filed with the Office of the City Clerk prior to being sworn in as a member. Page 3 of 6 F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx Updated: June 2020 ● Are you a registered active lobbyist with the City of Miami Beach? Yes or No ● Have you ever been convicted of a felony? Yes or No If yes, please explain in detail: ● Do you currently have a violation(s) of City of Miami Beach Code? Yes or No If yes, please explain in detail: ● Do you currently owe the City of Miami Beach money? Yes or No If yes, please explain in detail: ● Are you currently serving on any City Board or Committee? Yes or No If yes, which Board/Committee? ● In what organization(s) in the City of Miami Beach do you currently hold membership? _________________________________________________________________________________________________ Name Position _________________________________________________________________________________________________ Name Position ● List the address of all properties owned or in which you have an interest within the City of Miami Beach: _________________________________________________________________________________________________ _________________________________________________________________________________________________ ● Are you now employed by the City of Miami Beach? Yes or No If so, which department and title? _________________________________________________________________________________________________ ● Pursuant to City Code Section 2-25 (b): Do you have a parent , spouse , child brother or sister who is employed by the City of Miami Beach? Yes or No If “Yes,” identify person(s) and department(s):  Note: If applying for the At-Large position of the Historic Preservation Board, please answer the below questions: • Have you ever resided in one of the City’s Historic Districts for at least one year? Yes or No If you answered “Yes,” please indicate: From: To Address Dates From: To Address Dates Page 4 of 6 F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx Updated: June 2020 NOTE: IF APPOINTED, YOU WILL BE REQUIRED TO FOLLOW CERTAIN LAWS THAT APPLY TO CITY BOARD/COMMITTEE MEMBERS. THESE LAWS INCLUDE, BUT ARE NOT LIMITED TO: o Prohibition from directly or indirectly lobbying City personnel. (Miami Beach City Code Section 2-459) o Prohibition from contracting with the City. (Miami-Dade County Code Section 2-11.1) o Prohibition from lobbying before the Board/Committee you have served on for period of one year after leaving office . (Miami Beach City Code Section 2-26) o Requirement to disclose certain financial interests and gifts. (Miami-Dade County Code section 2-11.1) o Sunshine Law - Florida's Government-in-the-Sunshine Law was enacted in 1967. Today, the Sunshine Law regarding open government can be found in Chapter 286 of the Florida Statutes. These statutes establish a basic right of access to most meetings of Boards, Commissions, and other governing bodies of state and local governmental agencies or authorities. o Voting conflict – Form 8B is for use by any person serving at the county, city, or other local level of government on an appointed or elected Board, Council, Commission, Authority, or Committee. It applies equally to members of advisory and non-advisory bodies who are presented with a voting conflict of interest under Sectio n 112.3143, Florida Statutes. I HEREBY ATTEST TO THE ACCURACY AND TRUTHFULNESS OF THE APPLICATION ; AND I HAVE RECEIVED, READ AND WILL ABIDE BY CHAPTER 2, ARTICLE VII, OF THE MIAMI BEACH CITY CODE, ENTITLED “STANDARDS OF CONDUCT FOR CITY OFFICERS, EMPLOYEES AND AGENCY MEMBERS AND ALL OTHER APPLICABLE COUNTY AND/OR STATE LAWS AND STATUTES ACCORDINGLY.” _________________________________________________________________________________________________ Applicant’s Signature Date Name of Applicant (PLEASE PRINT) Board and Committee Application Checklist: Please ensure you have provided all information before applying or reapplying to any Board and Committee □ I have answered all questions fully. □ I have attached additional sheets, if necessary, to provide required information. □ I have attached a current resume, photograph, and a copy of any applicable professional license. □ I have completed and attached the Board & Committee Financial Acknowledgement Statement. □ I have completed and attached the Diversity Statistics Report. □ Submit complete application package. Via Email: BC@miamibeachfl.gov Via U.S. Mail or in Person: City of Miami Beach Office of the City Clerk / Board and Committee Section 1700 Convention Center Drive, 1st Floor Miami Beach, FL 33139 If you have any questions, please contact the Office of the City Clerk via email: BC@miamibeachfl.gov or telephone: 305.673.7411. Note: Florida Statutes §119.071: The role of the Office of the City Clerk is to receive and maintain forms filed as public records. If your home address, telephone numbers, and/or photograph are exempt from disclosure and you do not wish your home address, telephone numbers, and/or photograph to be made public, please: 1) Use your office or other address for your mailing address; 2) Use your office or other telephone number for your contact number; and 3) Do not attach a photograph. Page 5 of 6 F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx Updated: June 2020 BC@miamibeachfl.gov BOARD & COMMITTEE FINANCIAL ACKNOWLEDGEMENT STATEMENT Acknowledgement of fines/suspension for Board/Committee Members for failure to comply with Miami- Dade County Financial Disclosure Code Provision Code Section 2-11.1(i) (2) Last Name First Name Middle Initial I understand that no later than July 1, of each year all members of Boards and Committees of the City of Miami Beach, including those of a purely advisory nature, are required to comply with Miami-Dade County Financial Disclosure Requirements. One of the following forms must be filed with the City Clerk of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida, no later than 12:00 noon of July 1, of each year: 1. A “Source of Income Statement;” or 2. A “Statement of Financial Interests (Form 1)1;” or 3. A Copy of your latest Federal Income Tax Return. Failure to file one of these forms, pursuant to the Miami-Dade County Code, may subject the person to a fine of no more than $500, 60 days in jail, or both. Signature Date 1 Members of the Planning Board and Board of Adjustment will be notified directly by the State of Florida, pursuant to F.S. §112.3145(1)(a), to file a Statement of Financial Interests (Form 1) with the Miami-Dade County Supervisor of Elections by 12:00 noon, July 1. Planning Board and Board of Adjustment members who file their Form 1 with the County Supervisor of Elections automatically satisfy the County’s financial disclosure requirement as a Miami Beach City Board/Committee member and need not file an additional form with the Office of the City Clerk. However, compliance with the County disclosure requirement does not satisfy the State requirement. Page 6 of 6 F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx Updated: June 2020 Email: BC@miamibeachfl.gov DIVERSITY STATISTICS REPORT Last Name First Name Middle Initial The following information is voluntary and has no bearing on your consideration for appointment. It is being asked to comply with City diversity reporting requirements. Gender: Male Female Other I prefer not to answer. Race/Ethnic Categories: What is your race? African American/Black Asian or Pacific Islander Caucasian/White Native American/American Indian Other – Print Race: I prefer not to answer. Do you consider yourself to be Spanish, Hispanic, or Latino/a? Yes No I prefer not to answer. Do you consider yourself Physically Disabled? Yes No I prefer not to answer this question. Henry R. Williams (aka. Tiffany Fantasia) 820 Euclid Ave. apt 205 Miami Beach, FL 33139   Phone: (305) 215-7270 Email: sobetiffany@gmail.com Social Media:Facebook: @tiffanytfantasia Instagram: @Tiffanyfantasia Twitter: @Tiffanyfantasia       EDUCATION 1999-2002 Jazz Voice Major, Miami-Dade Community College 1995-1999 High School Diploma, Miami Sunset High School     EMPLOYMENT   Aug, 2003 - Present Drag Queen Tiffany Fantasia Performed at many clubs across the world, Show director/ Headliner at The Palace Bar on South Beach, MC for Miami Beach Gay Pride Parade, Curacao Pride, featured several times in Andy Cohen’s book Superﬁcial, the documentary South Beach on Heels and has made cameo appearances in several music videos and tv shows (WWHL with Andy Cohen, Bad Girls Club, Alaskan Women Looking for love.) Currently Hosting Palace Bar: Wednesday, Friday Lunch, Saturday Night shows  Titles: Miss Ultimate Miami 2018, Miss S.F. Illusions Plus 2016, Miss Miami Beach Pride 2013  Feb. 2016 - Sept. 2016 Singer/Server at National Hotel (The Cabaret)   Waited tables at while singing at The National Hotel. The Cabaret lounge was a unique experience in which everyone who worked at the establishment also sang songs for the guest.       July2008- February 2015 Staffer for Arrow Merchandising (Fossil Inc.) Representing Fossil and all of the brands under it’s belt. Sizing watches, Set up trunk show events and merchandised watches and leather goods . Held training seminars for Macy’s employee’s on Fossil, DKNY, and Diesel Watches. Organized backstock, kept inventory, and made sure merchandise was on display.         Oct.2005-Jun2008 Staffer for Kenneth Cole Watches Going into various Macy’s stores and selling, Kenneth Cole watches and it’s related brands, assisting in trunk shows, providing product knowledge to sales associates, communicating to my supervisor any stock that we might need, along with issues with certain watches.                   References available upon request.