Matthew Sarelson 12/31/2007 (2)
Note: If applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Center:
1. Past service on the Youth Center Advisory Board: Yes 0 No Ll Years of Service:
2. Present participation in Youth Center activities by your children YesfJ No [J. If yes, please list the names of your children, their
ages, and which programs. List below:
Child's name: Age: _ Program:
Child's name:
Age:
Program:
.Have you ever been convicted of a felony: Yes 0 or No aflf yes, please explain in detail:
· Do you currently have a violation(s) of City of Miami Beach codes: Yes 0 or No ~If yes, please explain in detail:
· Do you currently owe the City of Miami Beach any money: Yes 0 or No L/ If yes, explain in detail
· Are you currently serving on any City Boards or Committees: Yes 0 or No rn(lf yes; which board?
· What organizations in the City of Miami Beach do you currently hold membership in?
Name: (!jUT S oV+-"'l a e~ Title: H <oM l;qJ
Name: YUf {lO) :J:.v,(. Title: S"c> e -\~ y / t!:,od t1tM-l.ti"
· List all properties owned or have an interest in, which are located within the City of Miami Beach:
LOt/ I ~V; J ;~ A..Ie. P~)5 r113 ~'?> I ~ <9
· I am now employed by the City of Miami Beach: Yes 0 or N~hich department?
· Pursuant to City Code Section 2-25 (b): Do you have a parent 0, spouse 0, child 0, brother 0, or sister 0 who is employed by the
City of Miami Beach? Check all that apply. Identify the department(s):
This section is "not required" but desired: Age: 2. c:y years old Gender: Ma~ Female 0
Ethnic Origin (Check one)
Whit~frican-American/Black 0 Hispanic: 0 Asian or Pacific Islander 0 American Indian or Alaskan Native 0
Employment Status: Employe~etired 0 Home-maker 0 Other 0
"I hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
Article VII - of the City Code "Standards of Conduct for City Officers, Employees and Agency Members."
00()) 9
'0 ~ 30 V::07
Date )
%~
Name of Applicant (PLEASE PRINT)
HOI. H-l, ~ Soee-lsO)
Applicant's Signature
Please attach a copy of your resume to this application
NOTE: Applications will remain on file for a period of one (1) calendar year.
Date
Received in City Clerk's Office b
Name 0 Deputy Clerk
Document Control Number (Assigned by the City Clerk's Office)
Entered By
Date
Revised 1/25/07 jo
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F:\CLER\SALL\B&C Application\B&C Application Revised 091106 jakes.doc