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Dina Dissen 12/31/2010d] rs;igp,qlgEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.aov OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk Tel: (305) 673-741 1, Fax: (305) 673-7254 01 /08/2009 Dina Dissen 2474 Praire Ave Miami Beach, Florida 33140 Police Citizens Relations Committee Congratulations! You have been reappointed by Commissioner Jerry Libbin to the above referenced agency, board or committee for a term ending: 12/3112010. 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, ~o~~~~~~~~~ Robert Parcher City Clerk cc: Saul Frances, Parking Director Chief Carlos Noriega ATTACHMENTS: Letter of Appointment Oath City Code Ordinance section, applicable to agency, board or committee City Code Section 2-22, 2-23, 2-24, 2-25, 2-26, 2-2458, 2-459 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 We are committed to providing excellent public service and safely to all who live, work and play in our vibrant, tropical, historic community. }~ r' City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl,gov OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk Tel: (305) 673-741 1, Fax: (305) 673-7254 TO Dina Dissen RE: Police Citizens Relations Committee 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: 12/31/2010. 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/orida Commission on Ethics Guide to the Sunshine Amendment and Code of Ethics for Public ~cers and Emp/ogees, 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 committee on which I serve) on July 1st, following the closing of the calendar year on which I\have served. Dina Dissen Sworn to and subscribed before me this a- day of ~ , 200_.1 ~(,~r--- Silvia rieto Deputy Clerk *Please visit the City of Miami Beach website at www.miamibeachfl.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. m P/JA~^,IBEACH CI e ~` OF MiAMi BEACH BOARD ~;NI~ COMMITTEE APPI_iCA T ION FORM NAME: 1 I 1 `JcS ~/~ ~ 1 ,Q 6. Last ~Nadme o First Name p~ Middle Initial HOME ADDRESS: ~~ 1` ` 0 ~Q-~ CSC', ~"~ 1_ ' `~ ~~ ~3J~~~ No. Street City State Zip Code PHONE: ~~-- ~Co~ - ,~'~ ~ C~tylGC~it `~`~wn ~~ ~a,LlbA ~ Home Work Fax Email address Business Name: Position: Address: No. Professional License (describe) Street City State Zip Code 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 ownershiprnterest for a minimum of six months in a business established in the city. • Resident of Miami Beach for a minimum of six (6) months: Yes ®'or No ^ • Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes C3'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 'ddle Bea • 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 !31 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 Authorit * 0 Board of Ad~ustment* ^ Miami Beach Commission for Women ^ Bud et Adviso Committee ^ Miami Beach Cultural Arts Council ^ Ca ital Im rovements Oversi ht ^ Miami Beach Florida Sister Cities ^ Committee on Homeless ^ Normand Shores Local Gov't Nei h. Im rovement ^ Committee for Qualit Education in MB ^ Parks and Recreation Facilities Board D Communit Develo ment Adviso * ^ Personnel Board* ^ Communi Relations Board ^ Plannin Board ^ Convention Center Adviso Board olice Citizens Relations Committee 0 Cultural Arts Nei hborhood District Overla (CANDO ^ Production Indust Council ^ Debarment Committee ^ Public Safet Adviso Committee ^ Desi n Review Baard* ^ Safet Committee ^ Disabilit Access Committee ^ Sin le Famil Residential Review Panel 0 Fine Arts Board ^ Sustainabilit Committee ^ Ga Business Develo ment Ad Hoc ^ Trans arenc Reliabilit & Accountabilit Committee "TRAC" ^ Golf Adviso Committee ^ Trans ortation and Parkin Committee ^ Health Adviso Committee ^ Visitor and Convention Authorit * ^ Health Facilities Authorit Board ^ Youth Center Adviso Board ^ His anic Affairs Committee " Board Required to File State Disclosure form ,.;~~r;\SAL~\Boarc € ;,mm~-uttees\58~ Au~>iu~auon\6ix: Apgli~atior. P,evislac ? ^,30E.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 :flf yes, please explain in detail: . Do you curfently owe the City of Miami Beach any money: Yes 0 or No ~If yes, explain in detail • Are you currently serving on any City Boards or Committees: Yes or No ^. If yes; which board? • What organizations in the City of Miami Beach do you currently hold membership in? Name: Name: Title: • List all properties owned or have an interest in, which are located within the City of Miami Beach: . I am now employed by the City of Miami Beach: Yes ^ or No~Which department? • Pursuant to City Code Section 2-25 (b): Do you have a parent G, spouse C, child C, brother ^, or sister `who is employed by the City of Miami Beach? Check all that apply. Identify the department(s): This section is "not required" but desired: Age: years old Gender: Male 0 Female ^ Ethnic Origin (Check one) White ^Rfrican-American/Black ^ Hispanic: ^ Asian or Pacific !slander ^ American Indian or Alaskan Native ^ "I hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2, Article VII - of the City Code "Standards of Conduct for City Officers, Employees and Agency Members." ~ ~~=-"" ~--- 2~ a"~ ~`~ `~ll~ ~ '1~f 5 SSA/ Apptlcant's Signature Date Name of Applicant (PLEASE PRINT) Please attach a copy of your resume to this application NOTE: Applications will remain on file for a period of one (1) ca~ndar year. c.,.,.,i~,,.,,e.,r c+~*~ ~~ ~mninvari n Ratirarl n Hnme-maker ~ Other ^ -...r•-~ Received in City Clerk's Office by Name of Deputy Clerk Document Control Number (Assigned by the City Clerk's Office) --~,~~ Entered RevlBetl 0 /02~ LH Title: . _~",~< _-_~,c~oa~; „om.rut~ee ~` ,._ <v,;_~ .<..r;,,,e :<, f,uui~:;at:,. ,_:vi:2~ 1?_..~.