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HomeMy WebLinkAboutApplicationsAug 28 2008 3:29PM DISTRICT 8 BOARD MEMBER 3059952786 p. 2 ZIP. 33132 NAME: Richard o -- C) CITY OF MIAMI APPLICATION 07 for PLANNING ADVISORY BOARD and/or ZONING BOAR'. ,. rn i11 .cam w 0 I Mrs[ Name] (Midrffe) RESIDENCE: 5085 Northwest 7 Street #1012 (Address Llnet) Tapia -.1 _0 1V r cn •CT!(Last Name) 0 CITY. Miami HOME PHONE: (305) 305-5559 EMAIL: rtapia@dadeschools.net (Address -Line 2) STATE: Florida zip. 33126 CELL (305) 305'5559 FAX PRINCIPLE BUSINESS/EMPLOYER. Miami -Dade County Public Schools BUSINESS ADDRESS• 1425 NE 2 Ave #700 !Address LMel) CITY: Miami (Address Line2) STATE: Florida BUS. PHONE•(305) 995-2328 EXT Would you like to serve on the Planning Advisory Board? Would you like to serve on the Zoning Board? Please state if you have a preference for either board: Zoning Board Are you an elector of the City of Miami? 1. Describe the qualities, experience, expertise and/or abilities that you possess that would make you an effective board member that will act In the public interest. As a former member of the Code Enforcement Board in the City of Miami, I acquired experience and expertise on fife —City of Miami Zoning o--4iirance, and process in which it is enforce. Additionally, my -Wasters in Frubiic -Admiriistralion from -pi orida-lnternationaf niversalty has enabled -my a iiiiyTo serve with -a foundation ofknowledge re prg trig zoning issues in the City of Miami. ram fh-aasr[a-0iet.m Page 1 of 4 c — M gcr.Piuc. Trl!i'TTV ('I FRk' paaa_1714712 P=c1.1% Aug 28 2008 3:29PM DISTRICT 8 BOARD MEMBER 3059952?86 p.3 2. Describe your educational background and general knowledge of planning and zoning. I earned a Masters in Public Administration from Florida International University, which has enabled my ability to serve with a foundation of knowledge regarding zoning issues in the sty -of Miami. In particular, my graduate coursework focused on economic development and building vibrant communities throe fi zonin 3. Describe any prior community or personal involvement that you have had that demonstrates interest in and concern for planning and planning implementation. As aformer member of the Code Enforcement Board inthe City of Miami, I acquired experience and expertise on _ the City of -Miami Zoning ordinance. and process in wtiicii ICU enforce. t hvve been involved with different community action groups prang expertise regarding zon n issues m the. City of -Miami, and throudhiouf the Miami -Dade Community Councils to assure proper zoning of -the communities of Miami -Dade' —------- —._..— — -- -- co 4. Describe any planning or land use or growth management seminars thay-lre0'have attended. co Florida Intemational University graduate coursework in zoning and economic development. :: —0 5. Describe any membership in organizations having the primary aim of the furtherance of dissemination of knowledge of and support of sound planning and Implementation programs. A member or the American Society of Public Administrators _ 6. Describe any other activity evidencing knowledge and interest In the public purposes of planning and plan implementation. Throughout my work in Miami -Dade County Public Schools, I have extensive experience working with issues of concurrency of cing &1iami isade-Public Sct ts. AdditionaiiyTT-have been a6fe to acquire grey know ledge -feg3rding the issues in�udding susT�in�iliTe communffies. Form Boarde/MA-PABIM-0701.01 Page 2 of 4 ui ir-rP-PAAR G1 : F1 PM Frorn: 30S9992786 ID:CITY CLEW P1-ge:005 R=94. Aug 28 2008 3:29PM DISTRICT 8 BOARD MEMBER 3059952286ee P r p . 4 - cgo G ' ., A ✓�, :' I have read and understand the qualifications for members that are set forth in Sec 62-124 of the City Codb;jirfli'heeebeegetify that: (1) I do not have any interest in the profits or emoluments of any contract, job, work, or service for the cite" % p, (2) I arn in a position to represent the public Interest and do not have any personal or private interests likely resecrillict with the public interest. (3) I do not hold any elective office in any governmental authority in the county or the city. (4) I am not employed in a full-time capacity by any governmental authority in the ccurrty or the city. (5) As a member of the planning advisory board or of the zoning board I agree to participate in at least one seminar on planning or zoning to be held in Florida,•and approved by the city, during the course of each calendar year that I remain a member or alternate member of the planning advisory board or of the zoning board. (6) I acknowledge that I am subject to removal from the board If 1 fail to meet this requirement each and every year after assuming board membership or alternate membership. (7) As a prospective appointee 1 am subject to a personal appearance before the city commission, to afford the city commission an opportunity to ascertain my proficiency In the English language, educational background and general knowledge of planning and zoning. (6) I am an elector of the City of Miami. An 'elector of the City of Miami° means a person who: (1) is a citizen of the United States of America; (2) is 1B years of age or older; • (3) has not been adjudicated mentally incapacitated with respect to voting in Florida or any other state; (4) has not been convicted of a felony in Florida, or any other state, without having had his/her civil rights restored; (5) is a resident of the City of Miami; and (6) is registered to vote In the City of Miami agree to immediately notify the City clerk if 1 cease to be a resident and/or an elector of the city during the term of my office. I agree that if I were to become a candidate for elective political office during my term and qualify as a candidate for elective political office, such qualification shall be deemed a tender of my resignation from the board. I have read, understand and agree to comply with Section 2-611 of the Miami City Code which prohibits me from entering into any con- tract or transacting any business with the city or any person or agency acting for the city, or from appearing in representation of any third party before any board, commission or agency of which I am member. I also understand that prohibition upon activity which is set forth above remains in effect for a period of two years after I have left city service. 1 have read, understand and agree to comply with Section 2-6t3 of the Miami City Code which prohibits me from accepting, directly or indirectly, from any person, company, firm or corporation to which any purchase order or contract is or might be awarded, any rebate, gift, money or anything of value whatsoever, except where given for the use and benefit of the city. I have reed, understand and agree to comply with Section 2-815 and 2-617 of the Miami City Code which requires that I submit to the city clerk a complete itemized list of ail real property owned by me, whether the title be either legal or equitable, whether owned in whole or in pars, including corporate real property in which I have a controlling interest or I am an officer of such corporation. I agree to submit to the city clerk said information in the required form verified and under oath within 30 days of my appointment and I shall include the following information as to each parcel of land: (t) The legal description and common address; • (2) The municipal or county zoning classification wherein the property is located; and (3) The manner in which the property 18 presently being utilized. I understand that I am required to list only those real properties that are located within the corporate limits of the city or those properties located 500 feet beyond the corporate limits of the city. I agree to comply with all financial disclosure requirements of the City, the County and the State including the requirements set forth in Section 2-11.1 of the Miami -Dade County Code, and Florida Statutes Sec. 112-3145. i acknowledge that the code of ethics of Miami -Dade County shall apply to me as a member or alternate member of the planning advisory board or the zoning board and hereby agree to abide by all the provisions thereof. • For additional information on Code Citations, please visit the website of the Office of the City Attomey at htlpeesviv .miamigov.conV cityattomey/pagesllndex.asp for internet finks to citations_ I recognize that membership on the planning advisory board or the zoning board requires my regular attendance and participation at board meetings. I understand that attendance at board meetings is subject to the following point system: 1. Each member or alternate member of the planning advisory board and the zoning board who arrives after the beginning of the first agenda item or leaves before the termination of the last agenda item, at a regutarty scheduled meeting of the board, shall receive two points. 2. Any member or alternate member of the planning advisory board or zoning board who accumulates more than 15 points in one calendar year shall automatically be removed and the position declared vacant. Additionally. I understand that if I arn appointed to the zoning board and I am absent, for whatever reason, from more than frve (5) meetings in one calendar year, I shall be automatically removed from the board; or that if I am appointed to the planning advisory board and I arn absent, for whatever reason, from more than six (6) meetings in one calendar year, I shall be automatically removed from the board. • Forth Bo& &I A-PAE2a croird Page 3 of 4 Gild-r;=, rG1G1^ 07::E2PM From: 3059952786 ID:CITY CLERK Paee:804 R=a . Aug 28 2008 3:30PM DISTRICT 8 BOARD MEMBER 3059952786 P • 5 I hereby certify that all information in this application is complete, truthful, and accurate to the best of my knowledge and that I have read and understand the qualifications and conditions of membership listed in this application. Ammgftyp_mw _40404011t4ftfOomOrw ---,4qMOR4005icr' C717:;DPM Frnm: 7ASRRSP71RF, TD:CITY CLERK PacIF.:AA5 P=q7% Form Boards/MA-PAD/Z3-0701.01 •$. CITY OF MIAMI APPLICATION for PLANNING ADVISORY BOARD and/or ZONING BOARD --u NAME: Lewis James Beilman 111 0 Ts— n r (First Name) (Middle) {Last Name) n r— = . RESIDENCE: 2110 SW 3rd Ave Apt 2B -n----, (Address Linel) at c"),...: (Address Line 2) 2 o — 7 — Ce? CITY: Miami STATE: FL ZIP: 3025 (,) 0 al HOME PHONE: (786) 493-6297 CELL(786) 493-6297 FAX: (305) 377-74 EMAIL: Ljb373@yahoo.com PRINCIPLE BUSINESS/EMPLOYER: South Florida Water Management District BUSINESS ADDRESS: 2121 SW 3rd Ave 6thFloio. r (Addressn (Address Line 2) CITY: Miami STATE: FL ZIP: 33129 BUS. PHONE:(305) 377-7274 EXT. 7249 Would you like to serve on the Planning Advisory Board? ci Yes C No Would you like to serve on the Zoning Board? 0-, Yes C. No Please state if you have a preference for either board: No Preference Are you an elector of the City of Miami? q Yes :SHORT STATEMENT OF QUALIFICATIONS (If you require additional space, attach additional pages) 1. Describe the qualities, experience, expertise and/or abilities that you possess that would make you an effective board member that will act in the public interest. I recently moved to Miami and have a history of public service that would make me an effective board member. My backgroundincluclis service on the South Miami Planning aciaiThaTidThTNiofth-Miami Charter I consider volunteering in 'the community in which 1 live an irnportant civia responsibilitY: In addition I aiderStand how government functions, having worked in government for several years (Please see my attached resume for additional infoirnation on my work and volunteer history.) Page 1 of 4 2. Describe your educational background and general knowledge of planning and zoning. As I stated above, I have served on the South Miami Planning Board, so I have knowledge of how planning and zoning decisions are made. I also currently work for the South Florida Water Management District which is a state agency with water use planning functions. In addition I have a law degree and a bachelor's degree in political science, both of which help me understand how planning and zoning boards function as advisory and quasi- judicial boards in the local government framework. (Please see my attached resume for additional information.) 3. Describe any prior community or personal involvement that you have had that demonstrates interest in and concern for planning and planning implementation. 1 served on the South Miami Planning Board from October 2005 to November 2006. (Please see my attached resume.) During that time, I was a member of the American Planning Association and subscribed to the Journal of the American planning Association. l also read up on planning history in my free time. 4. Describe any planning or land use or growth management seminars thay you have attended. Over the past two years, I have attended the Florida League of Cities conferences in August. These conferences include workshops on planning, land use, and growth management issues. 1 also have attended workshops on these issues organized by the Miami -Dade County League of Cities and the Greater Miami Chamberi of Commerce. These workshops have focused on transportation, urban development, and housing issues, among other things. In addition, as an employee of the South Florida Water Management District, I have attended numerous water -use planning workshops. 5. Describe any membership in organizations having the primary aim of the furtherance of dissemination of knowledge of and support of sound planning and implementation programs. I was a member of the American Planning Association during the time t served on the South Miami Planning Board. __...... ................. 6. Describe any other activity evidencing knowledge and interest in the public purposes of planning and plan implementation. As a senior intergovernmental representative for the South Florida Water Management District, I help coordinate water -use planning activities with local government agencies. This includes assisting -with the monitoring of the -developmeiit- and--impiementation of local water -use permits " alternative water supply projects and water -restrictions, among other things. Form BoardsfMA-PAOIZO-0701.01 Page 2 of 4 u fV (� t.1 0 �..y `� ... -r fYi —1 > m ::i —ta• - - � =t w rut r v� CG.) 0 crl I have read and understand the qualifications for members that are set forth in Sec. 62-124 of the City Code, and hereby certify that: (1) I do not have any interest in the profits or emoluments of any contract, job, work, or service for the city. (2) i am in a position to represent the public interest, and do not have any personal or private interests likely to conflict with the public interest. (3) I do not hold any elective office in any governmental authority in the county or the city. (4) lam not employed in a full-time capacity by any governmental authority in the county or the city. (5) As a member of the planning advisory board or of the zoning board I agree to participate in at least one seminar on planning or zoning to be held.in Florida, and approved by the city, during the course of each calendar year that 1 remain a member or alternate member of the planning advisory board or of the zoning board. (6) I acknowledge that I am subject to removal from the board if I fail to meet this requirement each and every year after assuming board membership or alternate membership. (7) As a prospective appointee I am subject to a personal appearance before the city commission, to afford the city commission an opportunity to ascertain my proficiency in the English language, educational background and general knowledge of planning and zoning. (8) I am an elector of the City of Miami. An "elector of the City of Miami' means a person who: (1) Is a citizen of the United States of America; (2) is 18 years of age or older; (3) has not been adjudicated mentally incapacitated with respect to voting in Florida or any other state; (4) has not been convicted of a felony in Florida, or any other state, without having had his/her civil rights restored; (5) is a resident of the City of Miami; and (6) is registered to vote in the City of Miami I agree to immediately notify the city clerk if I cease to be a resident and/or an elector of the city during the term of my office. I agree that if I were to become a candidate for elective political office during my term and qualify as a candidate for elective political office, such qualification shall be deemed a tender of my resignation from the board. I have read, understand and agree to comply with Section 2-611 of the Miami City Code which prohibits me from entering into any con- tract or transacting any business with the city or any person or agency acting for the city, or from appearing in representation of any third party before any board, commission or agency of which I am member. I also understand that prohibition upon activity which is set forth above remains in effect for a period of two years after I have left city service. I have read, understand and agree to comply with Section 2-613 of the Miami City Code which prohibits me from accepting, directly or indirectly, from any person, company, firm or corporation to which any purchase order or contract is or might be awarded, any rebate, gift, money or anything of value whatsoever, except where given for the use and benefit of the city. I have read, understand and agree to comply with Section 2-615 and 2-617 of the Miami City Code which requires that I submit to the city clerk a complete itemized list of all real property owned by me, whether the title be either legal or equitable, whether owned in whole or in part, including corporate real property in which I have a controlling interest or I am an officer of such corporation. I agree to submit to the city clerk said information in the required form verified and under oath within 30 days of my appointment and I shall include the following information as to each parcel of land: (1) The legal description and common address; (2) The municipal or county zoning classification wherein the property is located; and (3) The manner in which the property is presently being utilized. I understand that I am required to list only those real properties that are located within the corporate limits of the city or those properties located 500 feet beyond the corporate limits of the city. I agree to comply with all financial disclosure requirements of the City, the County and the State including the requirements set forth Section 2-11.1 of the Miami -Dade County Code, and Florida Statutes Sec. 112-3145. I acknowledge that the code of ethics of Miami -Dade County shall apply to me as a member or alternate member of the planning advisory board or the zoning board and hereby agree to abide by all the provisions thereof. For additional information on Code citations, please visit the website of the Office of the City Attorney at http://www.miamigov.com/ cityattorney/pages/Index.asp for internet links to citations. I recognize that membership on the planning advisory board or the zoning board requires my regular attendance and participation at board meetings. I understand that attendance at board meetings is subject to the following point system: 1. Each member or alternate member of the planning advisory board and the zoning board who arrives after the beginning of the first agenda item or leaves before the termination of the last agenda item, at a regularly scheduled meeting of the board, shall receive two points. 2. Any member or alternate member of the planning advisory board or zoning board who accumulates more than 15 points in one calendar year shall automatically be removed and the position declared vacant. Additionally, I understand that if I am appointed to the zoning board and I am absent, for whatever reason, from more than five (5) meetings in one calendar year, I shall be automatically removed from the board; or that if I am appointed to the planning advisory board and l am absent, for whatever reason, from more than six (6) meetings in one calendar year, I shall be automatically removed from the board. Form BwrdsIMA-PAB/ZB-0701.01 Page 3 of 4 I hereby certify that all information in this application is complete, truthful, and accurate to the best of my knowledge and that I have read and understand the qualifications and conditions of membership listed in this application. t.3' Yes Print Name Lewis J. Beilman III Signature Date August 4, 2008 ************************************************* FURTHER INSTRUCTIONS ;Please complete this form and submit to: Office of the City Clerk ATTN: Assistant City Clerk 3500 Pan American Drive Miami, FL 33133 :Information may be copied and pasted into this form from other computer programs, i.e.: MS Word. Information that is typed directly into the form may be "Saved as Text" and:: then opened in other computer programs. For additional information on the Planning Advisory Board and/or the Zoning Board, please contact Ms. Teresita Fernandez, Executive Secretary, Hearing Boards, at (305) 416-2038 or email at: TFernandez aarniamigov.com ************************************************* Form boards/MA-PAB/ZB-0701.01 Page 4 of 4 Resume Lewis J. Bei!man III Lewis J. Beilman III 2110 SW 3rd Ave Apt 2B Miami, FL 33129 (786) 493-6297 or 1jb373@yahoo.com EDUCATION University of Maine Law School Portland, Maine Juris Doctorate, May 2000 J. D. cum laude. Rank: 18/83. G.P.A.: 3.10. Senior Editor, Ocean and Coastal Law Journal. Treasurer, Environmental Law Society. t) —, r= rn cn rn r— _.c -"p 7 uc Cri ,- -_. G s z Sacred Heart University Fairfield, Connecticut Bachelor of Arts in Political Science, May 1995 B.A. magna cum latide. G.P.A.: 3.69. Graduated in the top 6 percent of my class. Received the 1995 Medal of Excellence for having the highest G.P.A. among Political Science graduates. WORK EXPERIENCE South Florida Water Management District Miami, Florida April 2006 to Present. Senior Intergovernmental Representative. Act as liaison with state, county, and municipal agencies. Make presentations to government agencies and community organizations. Work with local governments on water -shortage enforcement issues. Write press releases and Op -Ed pieces. Support planning and implementation efforts on grant projects. Assist with resolution of' right of way disputes. Assist with planning and act as agency representative at outreach events. Write weekly intra-agency progress reports. Support development of outreach budget. Provide emergency management support during hurricanes. Attend meetings of community and business groups. Miami Dade College Miami, Florida November 2004 to March 2006. Grant Writer. Wrote grant proposals to federal, state, and private funding sources. Prepared program budgets. Researched funding opportunities. Submitted grant applications electronically or by paper. Prepared items for board review. Served on job -screening committees. Researched OMB Circulars and grant -related legislation. Assisted with the college's submission of more than $50,000,000 in grants, of \-vhich more than $30,000,000 was funded. Specialized in workforce development grants. Community Renewal Team, inc. Hartford, Connecticut November 2002 to November 2004. Planning Analyst. Researched and wrote approximately 40 new grant applications and renewal applications for a $50 million Community Action Agency. Applications resulted in over $4,000,000 dollars of new funding for the organization. Coordinated the filing of grant reports with state agency. Wrote feasibility report on Adult Daycare Center. Organized meetings with funders, community members, and government officials to ensure that the needs of Hartford's low-income community were met. Facilitated Urban -Suburban Dialogues on drug problems in Hartford. Mainely Newspapers Biddeford, Maine August 2001 to August 2002. 1 Resume Lewis J. Beilman III Editor, Biddeford-Saco-OOB Courier. Each week wrote four to five articles, an editorial column, police notes, and an interview for weekly community paper. Wrote editorial columns that took positions on single -payer healthcare, recycling, and animal rights, among other things. Acted as community liaison for paper. Supervised staff writers and coordinated contributing writers. Took photographs to accompany articles. Assisted with coordinating the publication of the paper. Legal Aid of Dade County Miami, Florida May 2000 to August 2001 Program Manager, Self Help Program. Supervised day-to-day operations of.the largest family -law pro se assistance program in the country. instructed staff paralegals on the appropriate procedural information to provide to pro se litigants. Wrote instructional materials for filing procedures. Oversaw the sale of legal forms and made deposits of the money obtained from those sales. Coordinated with judges, the Clerk of Courts, and other Miami -Dade County employees to improve the efficiency and effectiveness of the Self Help Program. Global Access Corporation Stamford, Connecticut February 1996 to June 1997. Deputy Director, ABLE Program. Wrote three business research reports that were published and used by international clients. Aided in the management of research reports written by consultants. Supervised interns and administrative staff of international market -feasibility research organization. Handled a variety of administrative tasks. VOLUNTEER EXPERIENCE Humane Society of Greater Miami North Miami Beach, Florida August 2007 to Present. Volunteer. Volunteer at Adopt -a -Pet outreach events. Staff and assist with set-up of large scale outreach events. North Miami Charter Board North Miami, Florida February 2007 to July 2008. Board Member. Attended meetings as needed. Studied city charter. Made recommendations on charter amendments to City Council. South Miami Planning Board South Miami, Florida October- 2005 to November 2006. Board Member. Attended meetings twice a month. Reviewed applications for variances and made recommendations to City Council. Advised City Council on changes to the Land Development Code and Comprehensive Development Plan. Human Services Coalition Miami, Florida January 2006 to April 2006. Volunteer Income Tax Assistance Volunteer. Received training on income tax preparation. Assisted low-income individuals with filing their federal and state tax returns. Promoted the Earned Income Tax Credit (EI'I'C) within the community. Democracv for Greater Hartford Hartford, Connecticut September 2003 to November 2004. District Coordinator. Developed strategies for outreach. Coordinated voter registration drives. Organized meetings. Conducted phone -banking drives. Presented reports at statewide meetings. 2 Rename Lewis J. Bethnal? III Community Renewal Team, Inc. Hartford, Connecticut January 2003 to April 2004. Volunteer Income Tax Assistance Supervisor. Received three-day training on income tax preparation. Supervised volunteers assisting low-income individuals with filing their federal and state tax returns. Promoted the Earned Income Tax Credit (EITC) within the community. Assisted low-income individuals with filing their state and federal income tax statements. Volunteer Lawyers Project Portland, Maine January 1998 to December1999 and August 2001 to August 2002. Volunteer. Answered phone calls regarding family law issues from low-income individuals. Provided legal information to callers that laid out various courses of action. Discussed with volunteer supervisors about best course of action and relayed that information to callers. TRAININGS AND INTERNSHIPS Leadership Miami Miami, Florida November 2006 to May 2007 Participant. Worked with group to develop first in Miami -Dade County Hurricane Preparedness Dog Fair project. Wrote and disseminated project press releases. Coordinated project development meetings with government and nonprofit sponsors. Participated in fund-raising activities. Pine Tree Legal Assistance Portland, Maine June 1999 to August 1999 Intern. Worked under the supervision of two family law attorneys. Assisted in writing a trial brief, a client memo, several motions, a divorce judgment order, and several client letters. Attended hearings, mediations, and case management conferences. State Representative Andrew Norton Hartford, Connecticut January 1995 to April 1995. Intern. Worked under the supervision of Rep. Norton. Wrote constituent correspondence. Attended legislative hearings and committee meetings. Answered constituent phone calls. Wrote paper on state budgetary process. U.S. Representative Christopher Shays Bridgeport, Connecticut September 1994 to December 1994. Intern. Worked under the supervision of Rep. Shays' staff. Wrote constituent correspondence. Clipped local newspaper articles about Rep. Shays and faxed them to his Washington, D.C. office. Answered constituent phone calls. Kept weekly journal of experience as intern. 3 NAME• Frank CITY OF MIAMI APPLICATION for PLANNING ADVISORY BOARD and/or ZONING BOARD (First Name) RESIDENCE: 686 NE 74th Street Kemp (Middle) (Address Line1) Rollason (Last Name) r ("1 CITY: Miami HOME PHONE. 758-6144 EMAIL:- follason(c�comcast.net (Address Line 2) STATE: FL Zip• 33138 CELL 299-7300 FAX: 758-6143 PRINCIPLE BUSINESS/EMPLOYER. Rodriquez and Quiroqa Architects Chartered BUSINESS ADDRESS• 2100 Ponce de Leon Boulevard (Address Line)) CITY: Coral Gables (Address Line 2) STATE: FI BUS. PHONE: EXT ZIP: 33134 Would you like to serve on the Planning Advisory Board? c Yes r No Would you like to serve on the Zoning Board? r Yes C No Please state if you have a preference for either board: No Preference Are you an elector of the City of Miami? r Yes SHORT STATEMENT OF QUALIFICATIONS (If you require additional space, attach additional pages.) 1. Describe the qualities, experience, expertise and/or abilities that you possess that would make you an effective board member that will act in the public interest. -40-years-experience-with-the-City-in-multiple-administrative-positions-ineluding-Fire--Marshal-and-Director-of------- - Building Department as well as Director for all three of the City's CRAB. Active with Belle Meade Home Owners Association and the MiMo Biscayne Association. Form Boards/MA-PAB/ZB-0701 01 Page 1 of 4 2. Describe your educational background and general knowledge of planning and zoning. I possess a BS in Fire Science and Safety from the College of Engineering at FIW.--My previous positions with the City required me -to --have more than-arlayman's knowledge of the various -codes -impacting -planning and-zoning.- 3. Describe any prior community or personal involvement that you have had that demonstrates interest in and concern for planning and planning implementation. Answered under Number 1, above - • 4. Describe any planning or land use or growth management seminars thay yothav`�e attended. I attended multiple related seminars while employed by the City of Miami and the CRA. 5. Describe any membership in organizations having the primary aim of the furtherance of dissemination of knowledge of and support of sound planning and implementation programs. Belle-MeadeHome-Owners-Association and-MiMo-Biscayne Association. 6. Describe any other activity evidencing knowledge and interest in the public purposes of planning and plan implementation. Form Boards/MA-PAWS-0701 01 Page 2 of 4 I have read and understand the qualifications for members that are set forth in Sec. 62-124 of the City Code, and hereby certify that: (1) I do not have any interest in the profits or emoluments of any contract, job, work, or service for the city. (2) I am in a position to represent the public interest, and do not have any personal or private interests likely to conflict with.the • public interest. (3) I do not hold any elective office in any governmental authority in the county or the city. (4) I am not employed in a full-time capacity by any governmental authority in the county or the city. (5) As a member of the planning advisory board or of the zoning board I agree to participate in at least one seminar on planning or zoning to be held in Florida, and approved by the city, during the course of each calendar year that I remain a member or alternate member of the planning advisory board or of the zoning board. (6) I acknowledge that I am subject to removal from the board if I fail to meet this requirement each and every year after assuming board membership or alternate membership. (7) As a prospective appointee I am subject to a personal appearance before the city commission, to afford the city commission an opportunity to ascertain my proficiency in the English language, educational background and general knowledge of planning and zoning. (8) I am an elector of the City of Miami. An "elector of the City of Miami" means a person who: (1) is a citizen of the United States of America; (2) is 18 years of age or older; (3) has not been adjudicated mentally incapacitated with respect to voting in Florida or any other state; (4) has not been convicted of a felony in Florida, or any other state, without having had his/her civil rights -restored; (5) is a resident of the City of Miami; and (6) is registered to vote in the City of Miami - I agree to immediately notify the city clerk if I cease to be a resident and/or an elector of the city during the terrr,of my office. I agree that if I were. to become a candidate for elective political office during my term and qualify as a candidate( for elative political office, such qualification shall be deemed a tender of my resignation from the board. o I have read, understand and agree to comply with Section 2-611 of the Miami City Code which prohibits me from entering into any con- tract or transacting any business with the city or any person or agency acting for the city, or from appearing in representation of any third party before any board, commission or agency of which I am member. I also understand that prohibition upon activity which is set forth above remains in effect for a period of two years after I have left city service. I have read, understand and agree to comply with Section 2-613 of the Miami City Code which prohibits me from accepting, directly or indirectly, from any person, company, firm or corporation to which any purchase order or contract is or might be awarded, any rebate, gift, money or anything of value whatsoever, except where given for the use and benefit of the city. I have read, understand and agree to comply with Section 2-615 and 2-617 of the Miami City Code which requires that I submit to the city clerk a complete itemized list of all real property owned by me, whether the title be either legal or equitable, whether owned in whole or in part, including corporate real property in which I have a controlling interest or I am an officer of such corporation. I agree to submit to the city clerk said information in the required form verified and under oath within 30 days of my appointment and I shall include the following information as to each parcel of land: (1) The legal description and common address; (2) The municipal or county zoning classification wherein the property is located; and (3) The manner in which the property is presently being utilized. I understand that I am required to list only those real properties that are located within the corporate limits of the city or those properties located 500 feet beyond the corporate limits of the city. I agree to comply with all financial disclosure requirements of the City, the County and the State including the requirements set forth in Section 2-11.1 of the Miami -Dade County Code, and Florida Statutes Sec. 112-3145. I acknowledge that the code of ethics of Miami -Dade County shall apply to me as a member or alternate member of the planning advisory board or the zoning board and hereby agree to abide by all the provisions thereof. For additional information on Code citations, please visit the website of the Office of the City Attorney at http://www.miamigov.com/ cityattorney/pages/Index.asp for internet links to citations. I recognize that membership on the planning advisory board or the zoning board requires my regular attendance and participation at board meetings. I understand that attendance at board meetings is subject to the following point system: 1. Each member or alternate member of the planning advisory board and the zoning board who arrives after the beginning of the first agenda item or leaves before the termination of the last agenda item, at a regularly scheduled meeting of the board, shall receive two points. 2. Arty member or alternate member of the planning advisory board or zoning board who accumulates more than 15 points in one calendar year shall automatically be removed and the position declared vacant. Additionally, I understand that if I am appointed to the zoning board and I am absent, for whatever reason, from more than five (5) meetings in one calendar year, I shall be automatically removed from the board; or that if I am appointed to the planning advisory board and I am absent, for whatever reason, from more than six (6) meetings in one calendar year, I shall be automatically removed from the board. Form Boards/MA-PAB/ZB-0701 01 Page 3 of 4 I hereby certify that all information in this application is complete, truthful, and accurate to the best of my knowledge and that I have read and understand the qualifications and conditions of membership listed in this application. 6' Yes Print Name Frank K. Rollason Signature Date May 23, 2008 r' FURTHER INSTRUCTIONS Please complete this form and submit to: Office of the City Clerk ATTN: Assistant City Clerk 3500 Pan American Drive Miami, FL 33133 Information may be copied and pasted into this form from other computer programs, Le. MS Word. Information that is typed directly into the form may be "Saved as Text" and then opened in other computer programs. For additional information on the Planning Advisory Board and/or the Zoning Board, please contact Ms. Teresita Fernandez, Executive Secretary, Hearing Boards, at (305) 416-2038 or email at: TFemandez@mismigov.corn Form Boards/MA-PAB/ZB-0701 01 Page 4 of 4 77. Form Boarus/MA-PAB23-0701-01 CITY OF MIAMI APPLICATION j3 '[.iAY 30 Pi 3: 35 "" m• : for PLANNING ADVISORY BOARD and/or ZONING BOARD ;, o'ra • l°s E ,Y1 . Chi a 00 ►^ reS NAME: �i ) (First Name) (Middle) (Last Name) i.) 26 1 50 y— 6-r re_e. r RESIDENCE (Address Linel) - (Address Line 2) CITY: M `01 STATE: •fit— ZIP- 33 13 HOME PHONE: (36 443° -7 CELL .3° --7).(3(0211 FAX• 31:35 3972-208 EMAIL- M-4-0 WI ►`{ vflt ao l • Cron') PRINCIPLE BUSINESS/EMPLOYER• OC- ingnc.,nQ CR-A BUSINESS ADDRESS: 524x> 'i" z- 1 ©,,., �,-. & I aO (Address Line (Address One 2) CITY: M "` ".-N STATE: �` ZIP. 3312(0 • BUS. PHONE: 3�'S �� �� �� EXT. Would you like to serve on the Planning Advisory Board? ('• Yes • No Would you like to serve on the Zoning Board? • Yes ( No Please state if you have a preference for either board: No Preference , 3 •fin lb 1 Are you an elector of the City of Miami? if Yes " s r .SHORT AMEN,I9NS you require additional sptali',ttach additional pages 1. Describe the qualities, experience, expertise and/or abilities that you possess that would make you an effective board member that will act in the public interest. iv a 'Co cl ,L.s%nenr a n 7 a� a,i- un 4 i mr+v �1Q I, h a Y l L�e,_J....... cll.-14he_ �' ..4..._ .Q Ill �q : -> r _ o ve r.. -._ n► e _..e. �►.!s, ez Vo I.v._ed..J n " t 44 k.u. .-'eF.�.. ( ,* __b.u_� ..h_ac... _..f., -_a - .ro,_t_�+ _.._. Q.Y.....J.+:S,.n.c..��--------- -� - .�-54�.✓J{_�(__....C�r1--.'F�!1l_� .-hY � 1^ o oert ic J e-v&1Qp1 ow...!.-._ .ait_L v Cord ,-P4mJ,_... c j revt f&1� �s. T Q✓1..._SPdQ./Q1 ►bc....`4.5..... -L.>.cfcl�- ._ k. 9.n's...._c. _6 ._.o.c 1,01?. k- v4✓\a • kOark (.u.�_t i caJC_LoperS..._. bn .f._ .j- ..... -._ Q(A� . t e..s. e_��s <44� c.c.c.c.s.V ., �.1 -1-10A -D a9e o Y.e.... . e.c.i._.... ...AaS - e- c s, -yepe{ cleYe (opMfr T _..a4. 1-.D( n,x_ed.-_ j,.o...t.k w-i hw- e %na.v,✓ n ..Lin - J Page 1 of 4 2. Describe your educational background and general knowledge of planning and zoning. hcq.da ['cc( (4k4 4(4t vuk), �rok2r I� ce✓i &c cc✓t f-Vs. Lc'1,21A--41 u L i. ..1e.. Z t.4 e pS- Q'..1.s Q-. have_ k...) 119. _Ice, 4,0 ..47 . F4. Q.. J 2 n. ► Ala ..s c�..u. �- ►gin c_... A X.p.ae r) c.r+C_-c 4.4 �sg l t.S:#R, e . 3. Describe any prior community or personal involvement that you have had that demonstrates interest in and concern for planning and planning implementation. I.o oY� ..w ► ............ k1�.. �_ (.,� o. 1� (rin�v,cc _ have v: ..en .t.n.S.1-,rup.1.9.t,. n �sn.��n� �c,m.. ,gin . �r S{,�o�, �%c d vents.. of Q. ._..-.� rovec4 ..4-lnce. GCr it. ..l ^ ke R 17 �.n r9-. w -� Ci-�q._' pig. her., s► e 1 a.� ,, J. .e. e Oo l -p4,._ k- s.pq.<, e • .W er ,.....1 A-ou-e_r4-C r. IA. t{ �ll.y1_-1 its Qris -0 ........Q12f CPC. s, C.Itak%- 4. Describe any planning or land use or growth management seminars thay you have attended. 1 I� . _.V(PJ.C� �.aeduk✓t4t(_$. ceK �rrs.r.- ).aS y _1.Uekn ow!, -1'►��. _. .. 0 + .- .....1Ata ...�.. c.t,,a lI1 e I .. 1., ......_V/404? .... cx 1.�+0 . . a- '-fie _ ..... c ,'2« ..04 i-✓tc(r_s _o4... M .t_.u. ✓v1.'. _. L 1._._. ---._ .j4av_e-...0 ....L:.lt_. _ _I,41etd-kil CLrL..k_. _5 .,. (J._,.ny _ .i..04 ctpi‘ 5. Describe any membership in organizations having the primary aim of the furtherance of dissemination of knowledge of and support of sound planning and implementation programs. 6. Describe any other activity evidencing knowledge and interest in of planning and n f-- k, plan�iymplementation. 4 L N2- �qhn.� cc1Vts.-.j boor a.•icl Z�✓,4n9 bar *'4" ,13 cc ,` -fie • 4ci( LIAR • L•►-� a/Moir , a •A .ti-e e 1-. 3 q .3 e_ k_I.. • _.._O. ✓`,' `i er-j--....: Form Boards/MA-PAB2B-0701.01 Page 2 of 4 cri the public rilirposes I have read and understand the qualifications for members that are set forth in Sec. 62-124 of the City Code, and hereby certify that: (1) I do not have any interest in the profits or emoluments of any contract, job, work, or service for the city. (2) I am in a position to represent the public interest, and do not have any personal or private interests likely to conflict with the public interest. (3) I do not hold any elective office in any governmental authority in the county or the city. (4) I am not employed in a full-time capacity by any governmental authority in the county or the city. (5) As a member of the planning advisory board or of the zoning board I agree to participate in at least one seminar on planning or zoning to be held in Florida, and approved by the city, during the course of each calendar year that I remain a member or alternate member of the planning advisory board or of the zoning board. (6) I acknowledge that I am subject to removal from the board if I fail to meet this requirement each and every year after assuming board membership or alternate membership. (7) As a prospective appointee I am subject to a personal appearance before the city commission, to afford the city commission an opportunity to ascertain my proficiency in the English language, educational background end generalr kpowledge of planning and zoning. (8) I am an elector of the City of Miami. An "elector of the City of Miami" means a person who: y (1) is a citizen of the United States of America; —c (2) is 18 years of age or older; — p (3) has not been adjudicated mentally incapacitated with respect to voting in Florida or any other state; (4) has not been convicted of a felony in Florida, or any other state, without having had his/her civil rights restored; (5) is a resident of the City of Miami; and (6) is registered to vote in the City of Miami I agree to immediately notify the city clerk if I cease to be a resident and/or an elector of the city during the term Si mj(ffictn I agree that if I were to become a candidate for elective political office during my term and qualify as a candidate fob elective political office, such qualification shall be deemed a tender of my resignation from the board. I have read, understand and agree to comply with Section 2-611 of the Miami City Code which prohibits me from entering into any con- tract or transacting any business with the city or any person or agency acting for the city, or from appearing in representation of any third party before any board, commission or agency of which I am member. I also understand that prohibition upon activity which is set forth above remains in effect for a period of two years after I have left city service. I have read, understand and agree to comply with Section 2-613 of the Miami City Code which prohibits me from accepting, directly or indirectly, from any person, company, firm or corporation to which any purchase order or contract is or might be awarded, any rebate, gift, money or anything of value whatsoever, except where given for the use and benefit of the city. I have read, understand and agree to comply with Section 2-615 and 2-617 of the Miami City Code which requires that I submit to the city clerk a complete itemized list of all real property owned by me, whether the title be either legal or equitable, whether owned in whole or in part, including corporate real property in which I have a controlling interest or I am an officer of such corporation: I agree to submit to the city clerk said information in the required form verified and under oath within 30 days of my appointment and I shall include the following information as to each parcel of land: (1) The legal description and common address; (2) The municipal or county zoning classification wherein the property is located; and (3) The manner in which the property is presently being utilized. I understand that I am required to list only those real properties that are located within the corporate limits of the city or those properties located 500 feet beyond the corporate limits of the city. I agree to comply with all financial disclosure requirements of the City, the County and the State including the requirements set forth in Section 2-11.1 of the Miami -Dade County Code, and Florida Statutes Sec. 112-3145. I acknowledge that the code of ethics of Miami -Dade County shall apply to me as a member or alternate member of the planning advisory board or the zoning board and hereby agree to abide by all the provisions thereof. For additional information on Code citations, please visit the website of the Office of the City Attorney at http://www.miamigov.com/ cityattorney/pages/Index.asp for internet links to citations. I recognize that membership on the planning advisory board or the zoning board requires my regular attendance and participation at board meetings. I understand that attendance at board meetings is subject to the following point system: 1. Each member or alternate member of the planning advisory board and the zoning board who arrives after the beginning of the first agenda item or leaves before the termination of the last agenda item, at a regularly scheduled meeting of the board, shall receive two points. 2. Any member or alternate member of the planning advisory board or zoning board who accumulates more than 15 points in one calendar year shall automatically be removed and the position declared vacant. Additionally, I understand that if I am appointed to the zoning board and I am absent, for whatever reason, from more than five (5) meetings in one calendar year, I shall be automatically removed from the board; or that if I am appointed to the planning advisory board and I am absent, for whatever reason, from more than six (6) meetings in one calendar year, I shall be automatically removed from the board. arm BoarUs/MA•PAB/ZB-0701.01 Page 3 of 4 e' I I hereby certify that all information in this application is complete, truthful, and accurate to the best of my knowledge and that I have read and understand the qualifications and conditions of membership listed in this application. Print Name Signature Date ® Yes k)(0.--edes 0 FURTHER INSTRUCTIONS Please complete this form and submit to: Office of the City Clerk ATTN: Assistant City Clerk 3500 Pan American Drive. Miami, FL 33133 Information may be copied and pasted into this form from other computer programs, i.e. MS Word. Information that Is typed directly into the form may be "Saved as Text" and then opened In other computer programs. For additional information on the Planning Advisory Board and/or the Zoning Board, please contact Ms. Teresita Fernandez, Executive Secretary, Hearing Boards, at (305) 416-2038 or email at: TFernandez@rniamlgov.com Form Boards/MA-PABIZ8-0701.01 Page 4of4 NAME: Hazem RECEIVED CITY OF MIAMI APPLICATIOI3 FEB 29 PH 3: 54 for PLANNING ADVISORY BOARD and/or ZIMING_BOARD!;,; ;?SON tiI _l ERr. CITY OF MIA"I. FL (First Name) RESIDENCE• 1703 SW 21st Street Monem (Middle) (Last Name) (Address Une1) CITY: Miami HOME PHONE: (305) 858-4551 EMAIL• hazem.monemekraft.com -(Address Line 2) STATE: Florida C ELL (305) 431-1710 PRINCIPLE BUSINESS/EMPLOYER• Edible Arrangements BUSINESS ADDRESS• 150 SE 2nd Ave, Suite 1-G (Address Linel) zip. 33145 FAX: (305) 858-4883 (Address Une 2) CITY: Miami STATE: Florida BUS. PHONE-(305) 577-6101 EXT. Would you like to serve on the Planning Advisory Board? t: Yes r No Would you like to serve on the Zoning Board? (: Yes C' No Please state if you have a preference for either board: No Preference Are you an elector of the City of Miami? zip. 33145 r Yes SHORT STATEMENT OF QUALIFICATIONS (If you require additional space, attach additional pages.) 1. Describe the qualities, experience, expertise and/or abilities that you possess that would make you an effective board member that will act in the public interest. I have lived all my life within the city of Miami limits and have witnessed several LIVE meeting and also watched several of-tf-ie broa c�asls meeting ori-PUB[ICT fevision 1�at is before if eye ciiangtheFilgfiel of anneli: Thive aiways had passion to lean about t`he govemini rulei for building within the cfy_ Ciof Miami. In addition, being one who has had several experiences with the building department as a business owner and a home owner is what has drawn me closer to volunteer my time to my city for whom which I care for. Form aoau dMA-PAa20.0701.01 Page 1 of 4 2. Describe your educational background and general knowledge of planning and zoning. I am graduate of Florida International University, with a major in business. My knowledge of planning and zoning stems from what 1 have read and researched In articles and books regarding setbacks, height limit, variances, etc. 3. Describe any prior community or personal involvement that you have had that demonstrates interest in and concern for planning and planning implementation:: G none '^ 'O r rn _W Tt r ,n V• - O 4. Describe any planning or land use or growth management seminars thay you helve attended. no seminars attended 5. Describe any membership in organizations having the primary aim of the furtherance of dissemination of knowledge of and support of sound planning and implementation programs. none 6. Describe any other activity evidencing knowledge and interest in the public purposes of planning and plan implementation. As a business owner in DOWNTOWN Miami, I was very much involved with the DOWNTOWN DEVELOPMENT AUTHOk1TY7I wolr ced witWi them very doseTy, f saw the work that was being put- rth behind the scenes prior to the rautiC Miamt11 21.T'prettymuch thin -We -city is he -ailed -In -the -right direction into creating a 2d"tur downtown. My business -contacts at -the VDA-areDavon"Barbaurand Leo Zabenskfl have -always tard the DDA if there is a project andyouneed merchants -to -be Involved -count mein: •" - Fom, 9o.r08&1414PA929-0701.o1 Page 2 of 4 1 have read and understand the qualifications for members that are set forth in Sec. 62-124 of the City Code, and hereby certify that: (1) I do not have any interest in the profits or emoluments of any contract, job. work, or service for the city. (2) I am in a position to represent the public interest, and do not have any personal or private interests likely to conflict with the public interest. (3) I do not hold any elective office in any govemmental authority in the county or the city. (4) I am not employed in a full-time capacity by any governmental authority In the county or the city. (5) As a member of the planning advisory board or of the zoning board I agree to participate in at least one seminar on planning or zoning to be held in Florida, and approved by the city, during the course of each calendar year that I remain a member or alternate member of the planning advisory board or of the zoning board. (6) I acknowledge that I am subject to removal from the board if I fail to meet this requirement each and every year after assuming board membership or alternate membership. (7) As a prospective appointee I am subject to a personal appearance before the city commission, to afford the city commission an opportunity to ascertain my proficiency in the English language, educational background and general.-1vroWedge of planning and zoning. (8) I am an elector of the City of Miami. An "elector of the City of Miami' means a person who: n _ � -- co �^' N (1) is a citizen of the United States of America; " 1 (2) is 18 years of age or older; (3) has not been adjudicated mentally incapacitated with respect to voting in Florida or any other state; %'r" (4) has not been convicted of a felony in Florida, or any other state, without having had his/her civil rights restr7 (5) Is a resident of the City of Miami; and „ C."." (6) is registered to vote in the City of Miami r— cri I agree to immediately notify the city cleric if I cease to be a resident and/or an elector of the city during the term of my ice. I agree that If I were to become a candidate for elective political office during my terrn and qualify as a candidate for elective political office, such qualification shall be deemed a tender of my resignation from the board. I have read, understand and agree to comply with Section 2-611 of the Miami City Code which prohibits me from entering into any con- tract or transacting any business with the city or any person or agency acting for the city, or from appearing In representation of any third party before any board, commission or agency of which I am member. I also understand that prohbition upon activity which is set forth above remains in effect for a period of two years after 1 have left city service. I have read, understand and agree to comply with Section 2-613 of the Miami City Code which prohibits me from accepting, directly or indirectly, from any person. company, firm or corporation to which any purchase order or contract is or might be awarded, any rebate, gift, money or anything of value whatsoever, except where given for the use and benefit of the city. 1 have read, understand and agree to comply with Section 2-615 and 2-617 of the Miami City Code which requires that I submit to the city clerk a complete itemized list of all real property owned by me, whether the title be either legal or equitable, whether owned in whole or In part, including corporate real property in which I have a controlling interest or I am an officer of such corporation. I agree to submit to the city clerk said information in the required form verified and under oath within 30 days of my appointment and I shall include the following information as to each parcel of land: (1) The legal description and common address; (2) The municipal or county zoning classification wherein the properly is located; and (3) The manner in which the property is presently being utilized. I understand that I am required to list only those real properties that are located within the corporate limits of the city or those properties located 500 feet beyond the corporate limits of the city. I agree to comply with all financial disclosure requirements of the City, the County and the State including the requirements set forth in Section 2-11.1 of the Miami -Dade County Code, and Florida Statutes Sec. 112-3145. I acknowledge that the code of ethics of Miami -Dade County shall apply to me as a member or alternate member of the planning advisory board or the zoning board and hereby agree to abide by all the provisions thereof. For additional information on Code citations, please visit the website of the Office of the City Attorney at http://www.mlamigov.com/ cityattorney/pages/Index.asp for Internet links to citations. 1 recognize that membership on the planning advisory board or the zoning board requires my regular attendance and participation at board meetings. I understand that attendance at board meetings is subject to the following point system: 1. Each member or alternate member of the planning advisory board and the zoning board who arrives after the beginning of the first agenda item or leaves before the termination of the last agenda item, at a regularly scheduled meeting of the board, shall receive two points. 2_ Any member or alternate member of the planning advisory board or zoning board who accumulates more than 15 points in one calendar year shall automatically be removed and the position declared vacant. Additionally, I understand that if I am appointed to the zoning board and I am absent, for whatever reason, from more than five (5) meetings in one calendar year, I shall be automatically removed from the board; or that if 1 am appointed to the planning advisory board and I am absent, for whatever reason, from more than six (6) meetings in one calendar year, I shall be automatically removed from the board. Form BoardlflAA.PAB2B-0701.01 Page 3 of 4 aarrrrr11ar1111/ M1r141a1*1►416 I hereby certify that all information in this application is complete, truthful, and accurate to the best of my knowledge and that 1 have read and understand the qualifications and conditions of membership listed in this application. (: Yes Print Name HAZEM MONEM Signature Date Monday, February 25, 2008 4i1/H*iMNM/MtMMMMMMMiNNM1MN1MMi/ FURTHER INSTRUCTIONS (Please complete this form and submit to: Office of the City Clerk ATTN: Assistant City Cleric 3500 Pan American Drive Miami, FL 33133 Information may be copied and pasted info this form from other computer programs, l.e. MS Word. Information that Is typed directly into the form may be 'Saved as Text' and !then opened in other computer programs. For additional information on the Planning Advisory Board and/or the Zoning Board, Iplease contact Ms. Teresita Fernandez, Executive Secretary, Hearing Boards, at (305) 416-2038 or email at: 1 TFernandggarti emigov.com rarrwrrrarw►rkrkfirtinkiM* N**d..Maaa/1+/f/fwear Form $ .MUh1A-PA&Z M701.01 Page 4 o! 4 PIS :C Wd 62 833 8CO1 rn CT) rri ri 0