_La.2.00),
Referred by: _______ _
Mayor or Commissioner
CITY OF SOUTH MIAMI BOARD/COMMITTEE APPLICA TION
6130 Sunset Drive
South Miami, FL 33143
Phone No. 305-663-6340
Fax No. 305-663-6348
1. I am interested in serving on the fonowing board(s)/committ«(s):
Green Task Force
FirB1 cbOitt
eRA Advisory Board
Tblrd choicf.
Planning Board
Sttond choice
Environmental Review
FOurlb chOice
2. Name: _____________________ G_a~ry_R_o_bi_ns_o __ n ______________________________ ___
(please print)
3. Home Address: 5630 SW 85th St., South Miami, Florida 33143
4. Business Address: ______________ -'-________________ _
5. gome Phone No. ________ _ Business Phone No. _3_05_.9_8_6._364_"_~ ___ _
Fax No.
6. ~maiJAddress: ______ ~g~ary~s_e_lIs_~~@~g_m_ail_.w_m ________________________ --____ ___
7. EducationnoegreeEarned:_B_S_in_M_a_rn_et_in~g_an_d_F_in_an_~ __________________ __
Pertinent Experience: took several classes in school in Ewlogy and our environment
Field Expertise: ~ _______________________ _
8. Commu.nity Service:
9.
10.
11.
12.
Pinecrest Elementary PTA, Beth Am Basketball Coacn, Gulliver PTA
Attached Resume: (Optional)
Are you a registered voter?
Are you a resident ofthe .City?
Do you have a business in the City'! N°E No .
No
yes~ Yes
Yes ,f
Please be aware that aU applicants who are appoirmd tQ any City hoard, commission or committee, as well as all
employees-and volunteers, who will provide any service or who may come into contact with vulnerable persons as
defined in Section 435.02, Fill. Stat. (including children and the elderly) in the course of their appointment,
employment 0' volunteerlsm, must compliance wilh Level II Backgrolind Screening and Fmgerprintillg
requirements as per, Florida Statute Ck. 435. Such individual must have passed the background screening to the
satisfaction of the City prio, to the appointment to the positWn or the start of any employment or volunteerism.
Signature:.....-...---;;.L/72 __ ---::-:--·~+-_~--~===~--=----::::::-7 Applicant
Date 4/21/2017
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Revised 4115'