_LbReferred bJ': _______ _
Mayor or Commissioner
CI" OF SOUTH MIAMi B@ARD/COMMITTEE APPI.ICA 1'10111
6130 Sunset Drive
S!JlIthMiami, FL 33)43
PhtmeNo.305-663-6340
Fox No. 305-663"6348
1.
2.
I am interested in serving on the following board(s)/committee(s):
~r!3en Task For'Ce.
First choice Second thoice
Third cbolce Fourtb choice
Naxne: ____________________ ~~~n~ru~re~rl~<.~L~lore~nle~-------------------------------
(pIe ... " print)
3. Home Address: 25:::8':.:4~S::.W::..8::'~s:::'r:cee::.l ____________ ----______________ ------__ --____ __
4. nusiness Address: __ --"' ______________________ _
s. Home l'bo.ne No. _________ _ :Susiness Phone No. ________ _
Fax No.
6. E-mail Address: _____ -'J~en:cn=ile:::r.:::ko:::rt::.h1:.:4@~gn:::'a:::iI::.c=om::..... _____________________________ ---
7. Ednc'a1io.n/Degrce Earned: Masters.in Urban Planning, Me'slers in Bvs!nessAdmlnislralion
Pertinent-Experience! 7 ~lJaf5 govemnmnlllxplHleJlce: Worked a! lhe CilY 01 Soulll Mlam! 6S Grants,8ml 'Sus\alnability Admlnlstrator-fo! 5 years .
and 2:years a,l Miarnl·Dad~ County as,a SpeciarPraJects Administrator in Parks, Recreation and Open $p~ces Oep.t
Field Expertise: ________________________ _
8; Commu.nity Service:
9.
10.
11.
12.
Attached ~esume: (Optional)
Are. yon a registered voter?
Are you a resideut of tbeCity?
Do you have a business in the City?
yes§
Ye.s ./
Yes.
NO E No
No I
Please be aware that all applicants wfliJ are .appointed/o any City board, commission or committee, as well as all
empioyees-andvo/ullteers, who will provide any service or who may come into contact with vulnerable persolls as
defined in Sec/ion 435.02, Fla. Stat. (including children al!d the elderly) In the course of their appointment,
employment or volunteerisll; must compliance with Level 11 Background Screenihg and· jiugerprinting
require11lellts as per, Florida Statute CII. 435. Such indlviduaJ must have passed tlte background screenlllg to the
satisfactioll of :~~~!:::::j7!!f!'0inlm.'!!!!J!UIte,positiiiii or tll.e slart of any employment orvolunteerism.
'/ Signature // Date ~2:::11c::41:::20::.:'::..8 __________ _
.,,,,,,,;c/ Applicant
Revised 4115
/