Mohammad Islam Application PackageMI AMI BE ACH EDOARD ANDO CCCIII TT TEE APPLUICA TININ
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P le a se list yo ur prefer e nce s in or d er of rank i ng: [1] first choice, [2] seco nd ch oi ce, and [3] third choice. Please note th at
o n ly th ree (3) ch o ices w ill b e o b serv ed by th e O ffi c e of th e C ity C lerk.
City Sta te
Affo rda b le H o usi ng Ad visory H ea lth Advisor y C ommitt ee N orma nd y Sho res Loc al Govern m ent
C om mitt e e Neigh bor hood Imp ro ve9pen t Distri ct
A dvisor y Counci l t
An ima l W e lfare C ommitt ee H ea lth Facil iti es A utho rity B oar d P arks and Recr eational Faci lities
Board
Art in P ub li c P laces C ommitt ee H ispan ic Affairs Commi ttee P erso nnel Boa rd
A udi t C ommi ttee H istor ic Pr es erv atio n B oar d # Pl anning Board L2-1
B lack Affairs Adv iso rv C ommitt ee H ousina A uthor ity P olice/Ci tiz en s Relations Commi tt ee
Bo a rd of A dj u stmen t H uma n R igh ts C ommitt ee P ro ductio n Industry Council
B u d g et Adviso ry Committee LG BTQ Advi so ry C ommitt ee P ro gram fo r Public Informati on
C ommitt ee
C om mi ttee for Q ual ity Educa tion in M arine & W aterfront P rotecti on S enior Affairs Com mitt ee
M ia mi B e a ch A uth o rity
C om mitt ee on th e H ome less M ayor's 41st Stre et Committee S ustai nab ility Committ ee L1[
C o n ve ntio n C e nter A d viso ry B oa rd M ayor's General O bl iga tion Bon d T rans po rta tion, Park ing, and Bicycle-
O versi ght C ommitt ee P ed estri an Facil iti es Commi ttee
C u lt ura l A rts C o u n ci l M ayor's Panel on Ocea n Drive Vi sitor and Conventi on Auth ority
D e si a n R e vi ew Boa rd Mi ami B each C ommi ssi on for W omen Y outh Commi ssion
D isa bi lity Acce ss C om mitt ee N ext G e neration C ounci l
lord»le HAu»5iyg Advisey co o t ·
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P ro fessi o na l Li ce nse
T ype of P rofess iona l li ce nse Li ce nse Numb er
Sta te of Iss uance Li ce ns e Iss uance D ate Lice ns e Expi ration D ate
N ote: If you a re see ki ng appoi ntme nt to a professi ona l sea t (e.g . attorn ey, architect , etc .), you must atta ch a co py of your
curr e ntl y effecti ve cor r espon di ng professio nal licen se.
Page 10f 6
F\CLER$ALLB OARD AND COMMIT TIES DATABASE\CHECKLIST MASTER\BOARD AND COMMITTEE APPLICATION.docx
Updated: June 2020
A F F ILIA T IO N W IT H TH E C ITY O F MIAMI BEACH
Pursuant to City Code section 2-22(4) a, b, and e: Members of Agencies. Boards, and Committees shall be affiliated
with the City. This requirement shall be fulfilled in the following ways:
a. Resident of the ciy for a minimum of six months: ve Eh a¡Eh
·lam a resident of. South Beach L } Middle Beach L l North Beach [I
Or
b. Demonstrates an owm;rshioerest (for a minimum of six months) in a business established in the City (for a minimum
of six months): Ye Dlorl INo
Ownership Interest" shall mean the ownership of ten percent (10%) or more (including the ownership of 10% or more
of the outstanding capital stock) in a business.
Business" shall mean any sole proprietorship, sponsorship, corpora tion, limited liability company, or other entity or
business association.
Or
c. Full-time employee ct such a business (for a minimum of six months); and I am based in an office or other location of
the business that is physically located in Miami Beach (for a minimum of six months): Yes LlorL ho
Notwithstanding the requirements set forth herein, the qualified full-time employee of a business must be approved by
a 4/7th vote of the Mayor and City Commission.
NOTE: Members of Agencies, Boards, and Committees shall be required to demonstrate compliance with the City affiliation
requirements of sections 2-22 (4) a and b of the Miami Beach City Code by executing an affidavit, stipulating that they
have met either (or both) of said affiliation requirements. The original affidavit shall be filed with the Office of the City Clerk
prior to being swom in as a member.
• I am applying for an appointment because I have special abilities, knowledge. and experience. Please list below:
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Page 2 of 6
FCLER$ALLB OARD AND COMMIT TIES DATABASE\CHECKLIST MASTER\BOARD AND COMMITTEE APPLICATION.docx
Updated: June 2020
• Are you a reg istered activ e lobb yist wi th th e City of Miam Beach ? Yes Dor No¿
• Have you ever been convicted of a felony? Yes O or No~ yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach Code? Yes L for Nol} If yes, please explain in detail:
• Do you currently owe the City of Miami Beach money? Yes L}or Nol>l if yes, please explain in detail:
• Are you currently serving on any City Board or Committee? Yes~ No O If yes, which Board/Committee?
Name Plsition
• In what organization(s) in the City of Miami Beach do you currently bold membership?
SuAaikljilHAq_ _)<siliv-4 d eww k
Name Position
• List the address of all properties owned or in which you have an interest within the City of Miami Beach:
}
_Aoo, piih3 Div , Mia.._ Gel £ 3\4)
±LA ±l , S!ST, fSak, Mia el. £er-lA).
• Are you now employed by the City of Miami Beach? Yes Oor No~ so, which department and title?
--------------------------------------------------------------------------------------
• Pursuant to city code section 2-25 (b): Do you_have a parent! l, spouse L l, cnnaL l brother Ll or sister LI
who is employed by the City of Miami Beach? Yes L lorNo Lk
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? YesLJ or Nolf
If you answered "Yes," please indicate:
From: To
Address Dates
From: To
Address Dates
Page 3of 6
F\CLER$ALLB OARD AND COMMIT TIES DATABASE\CHECKLIST MASTER\BOARD AND COMMITTEE APPLICATION.docx
Updated: June 2C20
N O T E : IF A P P O INT E D , Y O U W IL L B E R E Q U IR E D T O F O L L O W C E R TA IN L A W S T H A T A P P L Y T O C ITY
B O A R D/C O MM ITT E E M E M B E R S . T H E S E LA W S IN C L U D E , B UT A R E N O T LI M IT E D T O :
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 voling conflict of interest under Section 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
[] 1have answered all questions fully.
O I have attached additional sheets, if necessary, to provide required information.
O I have attached a current resume, photograph, and a copy of any applicable professional license.
O I have completed and attached the Board & Committee Financial Acknowledgement Statement.
O I have completed and attached the Diversity Statistics Report.
O Submit complete application package.
Via Email:. BC @@mieIibeachfflyy
Via U.S. Mail or in Person:
City of Miami Beach
Office of the City Clerk/ Board and Committee Section
1700 Convention Center Drive, 1s Floor
Miami Beach, FL 33139
If you have any questions, please contact the Office of the City Clerk via email: BC@@mii @giligacih ff gii 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.
Page4of6
F\CLER$ALLB OARD AND COMMIT TIES DATABASE\CHECKLIST MASTERBOARD AND COMMITTEE APPLICATION.docx
Updated: June 2020
MI AMI BE A CH
iay ef Mi Eea d»
1770IO CGamveetfiam Center Die
Mtitamii [eurdh, Hilbiida 33739
wqyww. mmiiagmi lggggggd ifl]_goy
OHRI CE OF THE COIT Y CCIE
Emil:. EC@@riamib eaiff y
Tell erpl ane. 30/5.67 3.7441 I
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(@) (2)
TsL+1 O +4 MED> P
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 $500, 60 days in jail, or both.
Signature Al Date /e\2oc° >
1 Members of the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuantto F.S. S112.3145(1)a), to file a Statement of Financial Interests (Form 1) with the Miami-Dade County
Supervisor of Elections by 12:00 noon, July 1. Planning Board and Board of Adjustment members who file their
Form 1 with the County Supervisor of Elections automatically satisfy the County's financial disclosure
requirement as a Miam i Beach City Board/Committee member and need not file an additional form with the Office
of the City Clerk. However, compliance with the County disclosure requirement does not satisfy the State
requirement
Page 5of6
F\CLER$ALLB OARD AND COMMIT TIES DATABASE\CHECKLIST MASTERBOARD AND COMMITTEE APPLICATION.docx
Updated: June 2020
MIAMI BEACH
alty af Mt: - Berl
1l70O (Cm«etí im Cemttear Dije
MMiimi BBerdh, Filamida 337739
wwiwiunsiv. mmiigmibbagagudi f]_gw
OFERI CE OF THE CCIT Y CCIEK.
Email: BC@mia nib eaiff y
Telephone: 305.673.7441
DIVERSITY STATISTICS REPORT
1Lw MO E±tM-ED P?
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:
ET Male
D Female
O Other
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
L_ African American/Black
l Asian or Pacific Islander
Ll caucasian/white
[]Native American/American Indian
O Other - Print Race: ------------ □I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
ere = No
O I prefer not to answer.
Do you consider yourself Physically Disabled?
Lee
No
O I prefer not to answer this question.
Page 6 of 6
FACLER$ALLBOARD AND COMMIT TIES DATABASE\CHECKLIST MASTER\BOARD AND COMMITTEE APPLICATION.docx
Updated: June 2020
R ES U M E
M oh am m ed Rafi q ul lsla m
10 04 Biar ritz Drive APT #3 - own er of th e property
M iam i Beach, FL - 33 141
Pho ne 786-30:li_3407- Em"1I· ;'"'("lC:h'.:.'1iVY'¾'y;1i::,r~;~t;;;,;;y;'°; Qt;n@1~rn;;;;;! f'{""':~"'c' »° » ··i±±±i±iii±ittici±iiist±ii5ii:iii
O bjective: To obtain a challenging and rew arding position in
w hich my skills and exp eri ence can be utilized to con tribute to
the goals of an organization wh ich offers growth and
advancement opportunities.
Edu catio n: B.S, in civil engineering (Bangladesh) passi ng year
1985.
P rofessio nal expe ri ence: I w ork ed as professi on al engi ne er and
built a lot of building s, roads, bridges, and culvert back hom e in
Bang ladesh . I wa s inv ol ved in a big project (D am construction)
and it was under Saudi Ministry of water and irrigation and got
a good rep utatio n and certi ficate. I w as site engi ne er in
diff erent site, such as coff erdam sl ur ry wall, pouring, con crete,
rock excavatior, consolidation grouting. O ver al l every site gain
huge knowledge with practical experience it was a very big
project 200 twenty nine S.R. project the consultant company
w as A L-Faisoí and Auxon intern ation al [ Am er ican consulting
firm]. Duration of this project from 1987 to 1992.
Th e n I w a s b e ck to m y h o m e co u n try sta rt w o rk i n g with th e
con s u lta n t c omp a n y (Pm a x co n s ul t an t ). A s an en gi n e er I w a s
in v o lv e in a ru ra l in f ra s tr u c t u re e p ic a ll y 3 6 0 ' lo n g b rid g e fu n d e d
b y the U.S. Aid, aica and other foreign com pan y . Al so involve
with a lot of small bridge culvert and road construction. Most
project basically for flood protection to save the coastal area
from the flood. So, I gain a lot of-experience about-flood
protection.
Business experience: Started a grocery store business in 1997
at 71°, Street Miami Beach area, then the second business
opened in 2001 at 71°, Street Miami Beach area. The third
business opened in 2003, named "STOP N SAVE" located at
1245- 71°, street Miami Beach FL 33141. Used to be 711, closed
that business in 2010. Opened farm store in Hialeah until 2012.
Finally, I opened a gas station in Key Marathon FL.
Lan g u a g es skill: English, Bangla, Spanish , Arabic, Hi n d u, and
Urdu.
Notary Public : Since 1999 working as notary public and
notarized lot of documents such as immigration document,
personal papers. Sometimes I worked as a U.S. notary public to
help th e mobile em bassy of Bangl adesh. Since 2001 in Miami
DADE county FL..
Home Owner: O w n some rental property maintain the property
in a nice manner.
M a ri t al s t a t u s : M a rr i e d .
Children one daughter and two sons
Reference
MR. Bruce Schinberg {Áttorney at law)
Address: 800 west Avenue Suite C-1 Miami Beach, Florida
33139
Contact number: 305-538-7575
Admilson Peterson ex-employee since 1997-2010
Contact number: 786-769-9345
Kam rul H assan Khan: Business owner
Contact number: 786-380-7817
At present board member City of Miami Beach sustainability
and resiliency committee.
Article: Miami Beach is a city located in MIAMI-DADE County
Florida. One of the largest populations in the County 87,779.
Miami Beach has been home to several residents from various
nationalities genders social and economics classes with
hundreds and thousands of visitors from around the world
travelling every year to tour the famous city. City of Miami
Beach has been a community to many of the US. ·Everyone here
has good relations with th eir neighbors and become frien ds.
We can help tc keep our community safe and clean place.
H o w I c a n im p r o v e t h e c it y
In the rainy season residents of Miami Beach facing big problem
with the drainage system due to flooding which is major issue.
As a professional, I can say that I w ill propose a plan to address
the issue and will ensure that this plan is executed. I will do my
best to ensure that our needs are met.
LAW OFFICES
KROOP & SCHEINBERG, P.A.
SOUTH BAY CLUB • SUITE C-1
800 WEST AVENUE
MIAMI BEACH, FLORIDA 33139
RICHARD I. KROOP
ALSO ADMITTED IN COLORADO
AREA CODE 3
538-7575
BRUCE J. SCHE INB ERG
CERTIFIED FAMILY MEDIATOR
COUNTY CIVIL COURT MEDIATOR
FAX
AREA CODE 3
538-4676
March 28, 2012
Personnel Department
Powerlink Settlement Services, LP
345 Rouser Road - Building 5
Coraopolis, PA 15108
Re: Mohammed Rafiqul Islam
Position Soug t: Notary / Closing Agent
Dear Sir or Madam:
I recently had the opportunity to work over a considerable period of time with members
of your company in a rather complex matter which after much effort on everyone's part
resulted in a successful closing.
Y ou provided the services of a traveling notary public who came to my office to
complete the transaction. That prompted me to write this letter.
I have been an attorney in South Florida for over 40 years whose practice has an
emphasis on both çommercial and residential real estate matters. My office is located
on that part of Miami Beach, known as South Beach which is unique in many ways
especially in the area of real estate because it attracts a large number of foreign
investors who for many of them English is not their primary language.
In my opinion, through past experience there are times when although someone at a
closing who is obviously from another country, may speak and apparently understand
English there can be a question of whether that person understands the nuisances of the
language needed to fully understand the text contained in certain closing documents.
I have for many years known Mr. Mohammed Raifqul Islam who advises that for a
considerable period of time has acted as a notary and closing supervisory agent in the
South Florida area.
His ability to speak English, Spanish, Bangla, Arabic, Hindi and Urdu languages taken
together with his willingness to travel throughout Florida would be a significant asset
to assist your company in closing transactions in general and specifically when the
ability to converse in these languages would make the closing process more
understandable for the parties involved.
Recommendation Letter 32812.d0c
P a g e 2
W ith M r. Islam's language sk ills, I believe that situations wherein non pr im ary English
speaking parties might later claim that they did not understand what they were signing
at a closing could be significantly minimized if not eliminated.
Also Mr. Islam's language skills would be beneficial in creating a comfortable and
more confident atmosphere for the persons attending a closing who might feel that they
are at a disadvantage when all the documents are in English and that is not their
prim ary language.
I therefore would ask that you consider using Mr. Mohammed Rafiqul Islam t o act as a
notary/ closing agent in transactions throughout the State of Florida.
Any arrangements you wish to make should be made directly with Mr. Islam.
Sincerely,
KROOP & S2HE INBE
4 i / ,/ ./..,·
/
B
A L-D AK H E EL CORP . & C O.
BISHA DAM PROJECT ade auiA--'
die! )y
H E A D O FF I C E - M AD IN A H AL -M U N A W A R A H
P .O .B O X 331- C A B LE : AL-DAEHEEL
T E L E X 5700 12 AL-DAKHEEL S. J. - C .R . 496
T E L . 82349 40 - FA X . 8260525
il' ull - -9 /' »'
all: Jg_rrs •
£1 .e-s ot+tt 5ls
A,ete Si.Nri4£, 0yiii
D A T E l2 June 1989
NO .
················· ~jl ll
)
SE R VI C E CERTIFI C AT E
TO WHOM IT MAY CONCERN :
This is to ce:ify that MOHD RAFIQUL ISLAM s/o Abdul Hamid Bhuiyan
Naticnality Bangladeshi by birth, has been serving in this company since
2.11.87 as a Site Engineer at the BISHA DAM PROJECT.
·-•i-'
• ••
During this period he successfully supervised the completion of the
slurry cut-off to the cofferdam, ( done by sub-contractor ) , & the con-
crete work involved, done by our own labour. He was also working in drill
ing and blasting ?or rock excavation.
During this period he has proved to be sincere, active & hard working
as well as trustworthy.
He is still working with the company on this project.
I wish him every success.in the future.
-=pp=a= .$~j"'.,>~~,.:.1..l\,J-:>~~ . ff,3%%%h ¿j 2y e.p%}% l(7 £ {Ç2)}
~
"" . ,,;<__::._" \· .;,.-;;•~,~ ' . -~ ~--.-:-:.• -e!-,, ?', ; "i ..._o°i . ~ "'"'-~-1.U ..,_,,:_, . .,,, .• ,, "st:kiss
} t ;t° !{{¿fi¢ j } j ¿ii V! ; /]iÁI/
Engr. Malek Ghazal
Executive Proj. Engr.
The following ts the authorised English tran sl ation of the original certificate and is valid
only with the ogina: Bangle certificate.
MON O GR AM
Ban gl ade sh U niv ersity of En gi n eeri ng & Technology,
Dhaka
CERTIFICATE
ln accordance with the statutes of the University
kl ohamm eù 3afíqul 3slam
having satisfactorily fulfilled all the academic requirements and
having received the approval of the Syndicate is hereby awarded,
with all the rights and privileges pertaining thereto, the degree of
BACHELOR OF SCIENCE IN CIVIL ENGINEERING
Final academic session Date of passing
1983-84 lartly 1985
He is placed in the
eron C 1ass
SIGNATURES
SEAL OF TH
UNIVERSITY
Vice-Chancellor
Registrar
p r e 29th 1febur1tar 1988 Controller of Examinations
Compared and V erified
<ars
CONTROLLER OF EXAMINATIONS