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Chae Dupont 12/31/2011~d~~ ~: 01 /21 /2009 Chae Dupont 345 Michigan Ave #11 Miami Beach, Florida 33139 SUBJECT-:- Miami Beach Cultural Arts Council Congratulations! You have been reappointed by the City Commission to the above referenced agency, board or committee for a term ending: 1213112011. If you are unable to accept this appointment, please notify the City Clerk's Office at (305) 673-7411. Please read the enclosed material carefully. Again, congratulations and good luck. Sincerely, Robert Parcher City Clerk c~ cc: Saul Frances, Parking Director V Gary Farmer 7j"~ ~~ I ~' ~~ - ~ - ATTACHMENTS: Letter of Appointment ,~ Oath ~ ~ ~ ~ ~~ ~. _ City Code Ordinance section, applicable to agency, board or committee y~ U ° ~ "^ ` ~~ City Code Section 2-22, 2-23, 2-24, 2-25, 2-26, 2-2458, 2-459 ~~ 1 l," ~~ Ordinance 2006-3543 -Amendment to City Code Section 2-22 Miami-Dade County Code Section 2-11.1 -Conflict of Interest and Code of Ethics Ordinance City Wide Permit Application - (Parking Department Form) Booklet -Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees 'z "_ ~ ~ ¢ I ~ i ~ ,~ .t fa I ~„e _ ,a City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl,gov OFFICE OF THE CITY CLERK, Robert Parcher, Ciry Clerk Tel: (305) 673-741 1, Fax: (305) 673-7254 TO Chae Dupont RE: Miami Beach Cultural Arts Council I do solemnly swear or affirm to bear true faith, loyalty and allegiance to the Government of the United States, the State of Florida, and the City of Miami Beach, and to perform all the duties of a member of the above-mentioned board or committee of the City of Miami Beach to which I have been appointed for a term ending: 12/31/2011. I have been issued a copy of Section 2-11.1 of the Miami-Dade County Code (Conflict of Interest and Code of Ethics Ordinance), as well as theF/o~ida Commission on Ethics Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees, and understand that as a member of a City of Miami Beach Board and/or Committee, I must comply with the financial disclosure" require- ments of Miami-Dade County or the State of Florida (depending on the board or committ eon which I serve) on July 1st, following the closing of the calendar year on which I have served. Chae Dupont Sworn to and subscribed before me this day o , 200 Kerry Hernandez .~-- Deputy Clerk *Please visit the City of Miami Beach website at www.miamibeadifl.gov under City Clerk/Board and Committees for additional information regarding the Financial Disclosure Requirements. We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community. ~ l~~lAl~~11 BEA~~ C-TY of MiAMi g~AC~ >B~ARD AND CCJMMlTTEE APPLiCATI®N FORM NAME: -!/ ~ ~ C.~ /~ f ~ ~ ~~ lT _ Last Name First Name Middle Initial HOME ADDRESS: ~ ~ S- ~ ! Gb~l C-? /~7'~ ,~ ~, Jy1 f J4 N~- ~ ~ `~' -~`~~ ~`'~~- No. Street City State Zip Code PHONE: ~ ~~~ ~~ V - ~ Z/ S Home Work Fax Email address Business Name: ~~1-~~- L~~--1- C?~L_.!'' ~S position: ?~7'~I2 ~ Address: (I~~ ~~. 7 c~ ~ ~ Z ~Z- M ,~' Jr't'L' ( ~ _,3 _~_~_ No. Street City State Zip Code ---~ Professional License (describe) I~LUJ2 l ~`7 l4-/2._ Expires: Attach a copy of the license Pursuant to City Code section 2-22(4) a and b: Members of agencies, boards, and committees shall be affiliated with the city; this requirement shall be fulfilled in the following ways: a) an individual shall have been a resident of the city for a minimum of six months; or b) an individual shall demonstrate ownership/interest for a minim m of six months in a business established in the city. • Resident of Miami Beach for a minimum of six (li) months: Yes ~ No ^ • Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (li) months: Yes ^ or No • Are you a registered voter in Miami Beach: Yes ~'or No ^ • (Please circle one): I am now a resident of: North Beach South Beach/ Middle Beach • I am applying for an appointment because I have special abilities, knowledge, experience. Please list below: Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that only three (3) choices will be observed by the City Clerk's Office. (Regular Boards of City) ^ Affordable Housin Adviso Committee ^ Historic Preservation Board* ^ Art in Public Places Committee ^Housin Authorit ^ Beach Preservation Board ^ Loan Review Committee" ^ Beautification Committee ^ Marine Authori ^ Board of Ad'ustment* iami Beach Commission for Women ^ Bud et Adviso Committee iami Beach Cultural Arts Council ^ Ca ital Im rovements Pro'ects Oversi ht Committee ^ Miami Beach Sister Cities Pro ram ^ Committee on the Homeless ^ Normand Shores Local Gov't Nei h. Im rovement ^ Committee for Quali Education in MB ^ Parks and Recreation Facilities Board ^ Communi Develo ment Adviso ^ Personnel Board* ^Communi Relations Board ^ Plannin Board ^ Convention Center Adviso Board ^ Police Citizens Relations Committee ^ Cultural Arts Nei hborhood District Overla CANDO ^ Production Indust Council ^ Debarment Committee ^ Public Safe Adviso Committee ^ Desi n Review Board* ^ Safe Committee ^ Disabili Access Committee ^ Sin le Famil Residential Review Panel ^ Fine Arts Board ^ Sustainabili Committee D Ga Business Develo ment Ad Hoc ^ Trans arenc Reliabili & Accountabili Committee "TRAC" ^ Golf Adviso Committee ^ Trans ortation and Parkin Committee ^ Health Adviso Committee ^ Visitor and Convention Authori ^ Health Facilities Authorit Board ^ Youth Center Adviso Board ^ His anic Affairs Committee Board Required to File State Disclosure form F:\CLERISALL1Baard & CommitteeslB&C Appiicationli3&C Application Revist;d 11130f3 2.doc 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 ^ No ^ Years of Service: 2. Present participation in Youth Center activities by your children Yes^ No ^. 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 ^ or No~lf yes, please explain in detail: • Do you currently have a violation(s) of City of Miami Beach codes: Yes ^ or No If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money: Yes ^ or No~lf yes, explain in detail • Are you currently servin on any City Boards or Committees: Yes ~r No ^. If yes; which board? Nj ~ C ft c-- k'~ - ~~~ ern ~~e o~ • What organizations in the City of Miami Beach do you currently hold membership in? Name: Name: Title: Title: • List all properties owned or have an interest ih, which are located within the City of Miami Beach: • I am now employed by the City of Miami Beach: Yes o^ ~ hich department? • Pursuant to City Code Section 2-25 (b): Do you have a parent ^, spouse ^, child ^, brother ^, or sister ^ who is employed by the City of Miami Beach? Check all that apply. Identify the department(s): R) This section is " of re uired" but desired: A e: ears old Gender: Male ^ Femalep.!< Race: White African-American/Black ^ White/Hispanic: ^ Asian or Pacific Islander ^ American Indian or Alaskan Native ^ Haitian: ^ Origin Ethnic: Hispanic: Yes or No "I hereby attest to the accuracy and ruthfulness of the application and have received, read and will abide by Chapter 2, Article VII - of the City Code "Stan ds of Conduct for City Officers, Employees and Agency Members." a~ ~ © ~h~ ~c~~an`~ Applicant's Signature Dat ~ Name of Applicant (PLEASE PRINT) Please attach a copy ofyour resume to his,application NOTE:..Applications will rertlain on fide for a period of one (1) calendar year: Employment Status: Employed ^ Retired D Hglne-maker ^ Offer ^ Received in City Clerk's Office by Name of Deputy Clerk Document Control Number (Assigned by the Ciry Clerk's Office) ~ Entered By Date r ~®/ ~-~" F:~CLER1$ALL;Board & ~-'ommittees\B&C AppficationlB&C Application ReviS~d 11130& 2.dac