Francisco Diez-Rivas ApplicationMI A MI BEA C H
D re, - 3.,
RECEIVED
EC 31 2020
CI TY OF M IAMI BEACH
OFFICE OF TH E OrTY C,/jl,,/era o
BOARD AND COMMITTEE APPLICATION
Last Name First Name Middle Initial
5 Col/s e 2lo2i o / 3/8o
Home Address City State Zip Code
3o52 /G 3 a3 o gz-oc, 3o5-94 73 y_ /aC«en».de
Cellular Telephone Work Telephone Home Telephone Email address
Sercy .a h ooac.ad Go g [y2 vape
Business Name Occupation
Q4SS y/O y237_ Don(_ y 33/72
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.
Affordable Housing Advisory Health Advisory Committee Normandy Shores Local Government
Committee Neighborhood Improvement District
Advisory Council
Animal Welfare Committee Health Facilities Authority Board Parks and Recreational Facilities
Board
Art in Public Places Committee Hispanic Affairs Committee Personnel Board
Audit Committee Historic Preservation Board * Planning Board
Black Affairs Advisory 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 Marine & Waterfront Protection Senior Affairs Committee
Miami Beach Authority
Committee on the Homeless Mayor's 41 st Street Committee Sustainability Committee
Convention Center Advisory Board Mayor's General Obligation Bond Transportation, Parking, and Bicycle-
Oversiaht Committee Pedestrian Facilities Committee
Cultural Arts Council Mayor's Panel on Ocean Drive Visitor and Convention Authority
Desian Review Board Miami Beach Commission for Women Youth Commission
Disability Access Committee Next Generation Council
1. 0l0yr-'ú _G0 [o oven@7
2. /22or s7
I
/E,oroo/e lo or, luso
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
current! effective corres ondin rofessional license.
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F:\CLERl$ALL\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTERIBOARD AND COMMITTEE APPLICATION.docx
U p d ate d : Jun e 20 2 0
A FF ILI A T IO N W IT H T H E C IT Y O F M IA M I B E A C H
P ursuant to C ity C ode sectio n 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 lkl or[lNo
• I am a resident of: South Beach O Middle Beach ~ North Beach O
Or
b. Demonstrates an ownership interest (for a minimum of six months) in a business established in the City (for a minimum
ot sx months): Yes lorhwo
"Ownership Interest" shall mean the ownership often 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 Llarh
Notwithstanding the requirements set forth herein, the qualified full-time employee of a business must be approved by
a 417th 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 sworn in as a member.
• I am applying for an appointment because I have special abilities, knowledge, and experience. Please list below:
t,
7
du_: Hmm /, ms eey y o/ye__my _cu o o«,, Duce
Page 2 of 6
F:ICLER\$ALL\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\BOARD AND COMMITTEE APPLICATION.docx
Updated: June 2020
• Ar e y o u a r e gi s t er e d a ct i v e lob b yi st wi th th e Ci t y of Miami Beach? Yes L l or No led
• Have you ever been convicted of a felony? Yes bl or No Ll If yes, please explain in detail:
A, Ks"voe , fA role zro/ooh P A ou hale ofo (qBgy
• Do you currently have a violation(s) of City of Miami Beach Code? Yes O or No tg!¡ If yes, please explain in detail:
• Do you currently owe the City of Miami Beach money? Yes Lll or No b$, If yes, please explain in detail:.
• Are you currently serving on any City Board or Committee? Yes l8ll or No OJ If yes, which Board/Committee?
• In what organization(s) in the City of Miami Beach do you currently hold membership? _ )
/a2or-1 (o Bo,I_Qyeoq//1 Co>a 0 hl_u o vo7 o9gorge
Name Position
Name Position
• List the address of all properties owned or in which you have an interest within the City of Miami Beach:
5u eo o//ys yo@e_ ti 2£ nm//Soot / 33/0
• Are you now employed by the City of Miami Beach? Yes ll or No bl 1 so, which department and title?
• Pursuant to City Code Section 2-25 (b): Do you have a parent O , spouse O , child O brother O or sister O
who is employed by the City of Miami Beach? Yes [ lorN PB
If "Yes," identify person(s) and department(s): _
* N ote: 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 O or No '6.a.
If you answered "Yes," please indicate:
From: To
Address Dates
From: To
Address Dates
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F:ICLER\$ALL\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTERIBOARD AND COMMITTEE APPLICATION.docx
Updated: June 2020
N O T E : IF A P P O IN T E D , Y O U W IL L B E R E Q U IR E D TO FO L LO W C E R T A IN LA W S TH A T AP P LY TO C ITY
B O A R D /C O M M IT T E E M E M B E R S . T H E S E LA W S IN C L U D E , B U T A R E N O T LI M IT E D 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 88 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 Section 112.3143, Florida Statutes.
I H E R E B Y A T T E S T TO T H E A C C U R A C Y A N D T R U T H FU L N E S S O F TH E A P P LI C A T IO N ; A N D I H A V E R E C E IV E D ,
R EA D A N D W IL L A B ID E B Y CH A P T E R 2, ARTI CLE V II, O F T H E M IA M I B E A C H C IT Y C O D E , ENT IT LE D "S TA N D A R DS
O F C O N D LJ T F QB,.-e lT Y O F F IC E R S , EM P L O Y E E S A N D A G E N C Y M E M B E R S A N D A L L OT H E R AP P LI C A B LE
C O TY Dy/S T A T E LA W S A N D ST A T U TE S :C OF IN G LY." (
(h,,'a o2o . rate«c o D óz-- us
N am e of A pp licant (P LE A S E P RINT )
B o ard an d C o m m itt ee A p p lic atio n C h ecklist: Please ensure you have provided all information before applying or
reapplying to any Board and Committee
[f] I have answered all questions fully.
D I have attached additional sheets, if necessary, to provide required information.
D I have attached a current resume, photograph, and a copy of any applicable professional license.
D I have completed and attached the Board & Committee Financial Acknowledgement Statement.
D 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, 1 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. 7 411.
N o te: Flo rid a Statutes §119 .0 71: 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.
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F:ICLER\$ALLIBOARD AND COMMITTIES DATABASEICHECKLIST MASTERIBOARD AND COMMITTEE APPLICATION.docx
U p d a te d : Ju ne 20 2 0
M IA M I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl,gov
RECEIVED
EC 31 2020
CITY OF MIAM I BEACH
OFFICE OF THE OTY CLERK
OFFICE OF THE CITY CLERK
Email: BC@ miamibeachfl.gov
Telephone: 305 .673 .7 411
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)
44,
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.
ne o . :ese forms, pursuant to the Miami-Dade County Code, may subject the person to a fine
A,, aRze9L, 60 days in jail, or both.
Signature
1 Memb er s 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.
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F:\CLER\$ALL\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\BOARD AND COMMITTEE APPLICATION.docx
Updated: June 2020
MIAMI BEACH
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeach[l.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
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:
JEJ Male
O Female
Lloher
O I prefer not to answer.
Race/Ethnic Categories:
W hat is your race?
O African American/Black
O Asian or Pacific Islander
S caucasian/white
D Native American/American Indian
D Other - Print Race: ------------ □I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
i ves
N o
O I prefer not to answer.
Do you consider yourself Physically Disabled?
Tves
2ANo
Dl I prefer not to answer this question.
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U p d a te d : Ju ne 20 2 0