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Dr. Andrew Nullman 12/31/2010t a ~ ~ .m ~.F ~ ..~ ~ ~ ~~ . ~ of Miami Math, 1700 Convention Center Drive, Miami Beach, Fbrida 33139, www.miamibeachfl.gov OFFICE OF THE CITY CLERK, Robert Percher, City Clerk TEL: (305) 673-7411, FAX: (3051673-7254 01-30-2009 Dr. Andrew Nullman ~SUBJECT~~~" Health Advisory Committee Congratulations! You have been appointed by the City Commission to the agency, board or committee named above for a term ending: 12/31/2010. Pursuant to Ordinance No. 2006-3543, commencing with terms beginning on or after January 1st, 2007, the term of board members who are directly appointed by a member of the City Commission shall automatically expire on December 31 of the year the appointing elected official leaves office. If you are unable to accept this appointment or have any questions, please call the City Clerk's Office at 305-673-7411. Please read the enclosed materials carefully. Congratulations again and good luck. Sincerely, Robert Percher City Clerk cc: Saul Frances, Parking Director Cliff Leonard 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, 2-458 and 2-459 Ordinance No. 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 Employee We are committed to providing excellent public service and sofely to all who live, work, and play in our vibrant, tropical, historic community m Ciq- of Miami Hoch, 1700 Convention Center Drive, Miami Beach, Fbrida 33139, www.miamibeachfl.gov OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk TEL: (305) 673-7411, FAX: (305) 673-7254 TO Dr. Andrew Nullman RE: Health Advisory 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 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 committee on which I serve) on July 1st, following the closing of the calendar year on which I hive served. Dr. Andrew Nullman Sworn to and subscribed before me this a- day of~~-°~ • , 200 ~_ Silvia Prieto Deputy Clerk *Please visit the City of Miami Beach website at www.miamibeachfl.gov under City Clerk/Board and Committees for additional information regarding file Financial Disclosure Requirements. We ore committed to providing excellent public service and sofety to all who live, work, and ploy in our vibrant, tropical, historic community. m n~i~,n~i~~~~~ NAME: ~U <~~~ Last Name HOME ADDRESS: ~'~'~' ~"`~~~~ ~~' No. Street City State Zip Code PHONE: 3'~ (4,'~-3 `-i~7'~- ~~.,}7 ~'3~('~~(~I~~-( ~3,,~;) ~3`ty}~fi ~~uil~~ ~~~y~r,..~, Home Work Fax Email address Business Name: ~~~L~ ~ `~ ~"'' ~~ P~ Position: ~~~~~~ ~~ Address: ~'7° 'z.. ~-ii-~a ~~ -~ ~ o ~>~i ~C,~wt fi- ~ 3 I~/'o No. Street City State Zip Code O/ La( Professional License (describe) 1 K Y'~u~ Expires: ~ Attach a cope 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 aty for a minimum of six months; or b) an individual shall demonstrate ownership~nterest 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~l or No ^ • Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes for 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 Beac • t am applying for an appointment because I have special abilities, knowledge, experience. Please list below: Y s ~ ~.~.,~ t.>,~~~- Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that only thn3e t3) 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 Authori * D Beach Preservation Board ^ Loan Review Committee* ^ Beautification Committee ^ Marine Authori * ^ Board of Ad~ustment* ^ Miami Beach Commission for Women D Bud et Adviso Committee ^ Miami Beach Cultural Arts Council ^ Ca ital fm rovements Oversi ht ^ Miami Beach Florida Sister Cities ^ Committee on Homeless ^ Normand Shores Local Gov't Nei h. Im rovement ^ Committee for Quali Education in MB ^ Parks and Recreation Facilities Board ^ Communit Develo ment Adviso * ^ Personnel Board* 0 Communi Relations Board ^ Plannin Board 0 Convention Center Adviso Board ^ Police Citizens Relations Committee ^ Cultural Arts Nei hborhood District Overla (CANDO ^ Production Indust Council ^ Debarment Committee ^ Public Safet Adviso Committee ^ Desi n Review Board* ^ Safet Committee ^ Disabilit Access Committee ^ Sin le Famil Residential Review Panel ^ 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 ~-lealth Adviso Committee ^ Visitor and Convention Authorit * ^ Heatth Facilities Authorit Board ^ Youth Center Adviso Board ^ His anic Affairs Committee * Board Required to File State Disclosure form Ci T 1` OF ME~,MI i3EAGH BOkRG ~.N© C;3MtVlE T TEE APPLICl~,TIOh FORM 1~~ z~ ~S ~, ;~ First Name Middle Initial ,_cR~SH'~U.&carc %: '.omr-nttees\6&`: ~.puin;auor~io~~ ~,opii::atio~ Revi~1>c ' , 30c.do 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~f yes, please explain in detail: . Do you currently have a violation(s) of City of Miami Beach codes: Yes ~~ or No ~f yes, please explain in detail: • Do you currently owe the City of Miami Beach any money: Yes ~~ or No ~f yes, explain in detail • Are you currently serving on any City Baards or Committees: Yes ^ or No ~f yes; which board? • What organizations in the City of Miami Beach do you currently hold membership in? Name: Name: . List all properties owned or have an interest in, which are located within the City of Miami Beach: ~~tn~nrM ti<},~1r~ ~s -L~'z; rL~v1TM- ~~ • 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 ~, 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 ~ Female ^ Ethnic Origin (Check one) White ^Afrlcan-American/Black ^ Hispanic: ^ Asian or Pacific Islander ~ 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 -oft a Ci ode "Standards of Conduct for City Officers, Employees and Agency Members." Applicant'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) calendar year. Employment Status: Employed ^ Retired ^ Home-maker ^ Other ^ Received in City Clerk's Office by Date ~ ~__ ~-1__ U Name of Deputy Clerk C ,D,~ ~,, ~j Document Control Number (Assigned by the City Clerk's Office f ~ Entered '~'~`~' "' ` Date ~ 3 ~/ RewaeC osiozros ~r Title: Title: