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2.4)01
Re/t!FFt!d by: --'--::---:--:-__ _
Mayor or Commissioner
CITY OF SOUTH MIAMI BOARD/COMMITTEE APPt.ICATION
6130 $/llIsel Drive
SQutllMiami,FL 33143
PI,oneNo. 305"663-6340
Fax No. 3(j5-663·6348
1. I am interested in serving on tbe following board(s)/committee(s):
BUdget Commille~
First cbQite Second choitt
Third cboi<!e Fourth cboice
Name: _________ ~~J=.=nn=i~=r=K=.l~'o~~=nt::..------------------
(please print)
2.
3. Home Address: =-5a:::1=4=-sW==-81=S:::'~:.:.::t ___________ ~ __________ ----
4. Business Address: ___________________ _,.--__ -----
5. Home ~hone NQ. _________ _ Busin~ss ~hone No. ________ _
Fax No.
6. E-mail Address: _____ -'--J._"n~jf~:..r._ko_rth_1_4@::;g"m_._!l.c_o_'"' __________________ _
7. Eduea.ionIDegree Earned: Masters In Urban Planning, Masters In Business Administration
Pertinent Experience: 7 ye~rs·goverllm;mtfl~pll"~l!nce: WO/kcd at the Clly,orSoulil MI<lm5 as Grants and SlJslaioalJilily Admlnislralurlor 5yeara
and 2 years at MJaml-Dade CO,llnty as a Special Projects Admbilslrator In Pa,lks. Recreation and Qpen Spaces, Dept
Fi~ld Expertise: _______________ ~--_____ _
8. C()J1lDIllnityService:
9.
10.
11.
12.
Attached Resume: (Optillnal)
Are you a registered voter?
Are you a resident of the .City?
Do you have a buSiness in the City?
NO~ No
No .f
yost!
Yes
Yes
Plellse be aware thllt 1l11llpplicants 11'110 are appointed to'any City board, commission or committee, as well as all
employees·and volunteers, 11'110 wl1l provide any service or Who »Jay come illto cOlltact witllvulllerable persons as
defined in Section 435.02, Fla. Stat. (including children alld the elderly) in the course of tlleir Ilppointmellt,
employmen/ or volunteetism, must compllallce with Level II Background Screening alld fingerprInting
requiremenls as per, Florida Statute Ch. 435. Such individual must /,ave passed ti,e background screenillg to the
salis/actioll of tile C~P'" to the appolllimellt to the posilioll or the start of allY employmelll or volunleeTism.
"/~/?
Signature C. ~_ Date :;.2''''14::.:/2::.01'''8 ____ _
~?> Applicant -=::0::::::,
t~/
Revised 4115