Evan Rubensteen Application PackageRubensteen Evan
Last Name First Name Middle Initial
4035 North Meridian Ave Apt 102 Miami Beach
Home Address City
FL 33140
State Zip Code
305-672-2260
HomeWork
staff@miamibeachorthodontics.com
Email Address
917-224-4222
Cellular
Miami Beach
Business Address
939 Arthur Godfrey Road
City
FL
State
33140
Zip Code
Miami Beach Orthodontics
Occupation:Business Name:
Orthodontist
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 City Clerk’s Office. (Regular Boards of City)
Choice 1:
Choice 2:
Choice 3:
Health Advisory Committee
Health Facilities Authority Board
Mayor's 41st Street Committee
BOARD AND COMMITTEE
APPLICATION FORM
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?No
No Address in City Historic District submitted.
Professional License
License Number Issuance Date Expire Date
State of Florida Department of
Health Division of DN 19109 2/18/2020 2/28/2022
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.
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:
YesResident of the City for a minimum of six (6) months:
Demonstrate an ownership interest in a business established in the City for a minimum of six (6) months:Yes
AFFILIATION WITH THE CITY OF MIAMI BEACH
a.
● I am resident of:South Beach
Or
b.
"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.
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
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 section 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 filled
with the Office of the City Clerk prior to being sworn in as a member.
Or
No● Have you ever been convicted of a felony:If yes, please explain in detail:
● Do you currently have a violation(s) of City of Miami Beach codes:No If yes, please explain in detail:
● Do you currently owe the City of Miami Beach any money:No If yes, please explain in detail:
● Are you currently serving on any City Boards or Committees:No If yes, which board?
● Are you presently a registered lobbyist with the City of Miami Beach?No
● I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
I would like to apply for a position on one of the following Miami Beach committees 1) Health Advisory
Committee, 2) Health Facilities Authority Board, 3) Mayor’s 41st Street Committee. I have been involved with
governmental planning as I am the representative for Miami Beach/North Dade to represent
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 board/committee you have served on for period of one year after leaving office
(Miami Beach 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 equality to members of
advisory and non-advisory bodies who are presented with a voting conflict of interest under Section 112.3143.
Florida Statutes.
● In what organization(s) in the City of Miami Beach do you currently hold membership in?
No Organization Information Submitted.
● List the address of all properties owned or in which you have an interest within the City of Miami Beach:
No Owned Property Information submitted.
If so, which department and title?No● Are you now employed by the City of Miami Beach:
● 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?No
If "Yes", identify person(s) and department(s):
No relative's information submitted.
BOARD & COMMITTEE FINANCIAL ACKNOWLEDGEMENT STATEMENT
Acknowledgement of fines/suspension for Board/Committee Members for failure to comply with
Miami-Dade County Financial Disclosure Code Section 2-11.1(i)(2)
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 filled 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.
_____________________________
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.
DIVERSITY STATISTICS REPORT
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.
WhiteRace/Ethnic Categories
What is your race?
No details providedOther Description:
Gender:Male
Are you Spanish/Hispanic/ Latino? Mark the "No" box if not Spanish / Hispanic / Latino.No
Physically Challenged:No
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.”
I Evan Rubensteen agreed to the following terms on
Received in the City Clerk's Office by:
Name of Deputy Clerk Control No. Date
Board and Committee Application Checklist: Please ensure you have provided all information before applying or
reapplying to any Board and Committee.
YES
YES
YES
YES
I have answered all questions fully.
I have uploaded a current resume, photograph, and a copy of any applicable professional license.
I have completed and attached the Board & Committee Financial Acknowledgment Statement.
I have completed and attached the Diversity Statistics Report.
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.
Evan Rubensteen, D.M.D., M.S.
Licensed in Florida, “NERB Status”
EvanRubensteen@gmail.com
(917) 224-4222
WORK
EXPERIENCE/
RESEARCH
Miami Beach Orthodontics, Owner
Full-time Orthodontic Associate at Gentle Dental Group
Orthodontic Associate at Brilliant, Rothenberg and Meister,
LLP
Cone beam CT (CBCT) Scan Analysis of the Posterior
Airway Space of Children with Obstructive Sleep Apnea
• SAO and UF funded research project
Determination of the Effectiveness of the American Dental
Association in Communicating Its Policies and
Recommendations
• Worked with Dr. Nina Anderson and Dr. Donald Giddon
• Analysis of the oral health literacy of patients presenting to the
Harvard Dental Center
Research Analyst at Children’s Hospital, Boston
• Paid position working on an NIH funded research project on
chronic pelvic pain syndrome
• Coordinated sample submission for saliva based DNA testing
Harvard Medical and Dental School Resident Advisor
• Planned various dormitory events
Centro de Salud Publica, Hospaitalito Barbara & Clinica
Dental Tacaton
• Provided dental services and general medical services at three
different sites in Guatemala
• Organized a fluoride project for 600 children in rural
Guatemala
Pinnacle Real Estate Group, NY, NY
• Managed accounts, billing
• Researched new investment purchases (10,000+ units)
Production Assistant at Schofield Films
• Assistant to the Producer and Project Manager
February 2016- Present
July 2013-January 2016
May 2012- June 2013
May 2009-April 2012
July 2007- May 2009
Summer 2007
August 2007–June 2008
Summer 2006
Summer 2005
Summer 2003
EXTRA-
CURRICULAR
ACTIVITIES
AND
LEADERSHIP
AWARDS AND
HONORS
VOLUNTEER
EXPERIENCE
FOREIGN
LANGUAGES
INTERESTS
• Worked to obtain permits for filming
• Laid out plans for actors’ residences during filming
• Coordinated communication on set
Harvard School of Dental Medicine Class President, Four terms
Alpha Omega President, Treasurer, Two terms
NYU College of Arts and Science Class President, Three terms
Chair of the NYU Undergraduate Art Conference and Co-Editor
of its publication, Reflections
NYU Student Council Alumni Committee
NYU Water Polo Team
Harvard Dental Bulletin Student Spotlight
Paul Dudley White Traveling Fellowship
NYU Founder’s Day Award
NYU Red Dragon
NYU College of Arts and Science, Presidential Scholars Program
Obtained donations for three fluoridation missions after my own:
1. Chile 2007
2. Peru 2007
3. Vietnam (500 children) 2008
Special Olympics / Special Smiles Coordinator
Project Bridge: volunteered at a program to provide free dental
treatment to runaway teens
HSDM Toys for Tots Toy Drive
Give Kids A Smile
Operation Mouthguard
Xavier Soup Kitchen
Habitat for Humanity, spent a week during Fall break 2001 building
homes
Hebrew (intermediate) Spanish (intermediate)
Aquaculture, Painting, Surfing, Sailing, Scuba Diving, and Film
Production
References available upon request