Scott Robins
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: (3051 673-7254
01 /14/2009
Scott Robins
1800 W. 24th St
Miami Beach, Florida 33140
~SU`~ JEC y ~~r Public Safety Advisory Committee
Congratulations! You have been reappointed by Commissioner Saul Gross
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,
,~/,-, ~ ~~ Z 5
Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
Chiet 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 safety io all who live, work and play in our vibrant, tropical, historic community.
I•
Cifr of Miami death, 1700 Convention Center Drive, Miami Beach, Fbrido 33139, www.miamibeochA.gov
OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk
TEL: (305) 673-7411, FAX: (305 673-7254
TO Scott Robins
RE: Public Safety 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: 12/31/2009.
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 Officers 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 caler3d ___ nwr served.
--.._„
Scott Robins
Sworn to and subscribed before me this~~ay of ~! /~~'! , 200
,~--~-~-~ Z-r fir .``vC.-~' -L- e'
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 the Financial Disclosure Requirements.
We are commined to providing excellent public service and safety to all who live, work, and play in our vibrant, tropical, historic community
m MIAMIBEACH
BOARDS AND COMMITTEE APPLICATION FORM
Pursuant to City Code section 2-2?_(4) a grid b: Members of agencies, boards, and committees shall be affiliated with the city; this requirement shall
be ful{filled 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 minimum of six months in a business established in the city.
Resident of Miami Beach for a minimum of six (b) months: Yes [' ~_] ~ or No [ ]
Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (b) months: Yes or No [ ]
I am applying for a Board appointment because I have special abilities, knowledge, experience: Yes
My special abilities, knowledge, or experience is:
Are you a reg;~tered voter in Miami Beych: Y or No ^ ~„~
-:--
NAM E : ~ ~ ~ ~ ~~, ~ ~~
ast dame first Name Mid Ipit~"al .
Home ~ T ~iLs ~,',' ~ t~`~~ (~~ `~~1'~ ~ 1 ~ ~~ ~ 1 ~ ~- ~~~ ~ ~ ~-
Address: No. 7 Street --~ /City /State/ Zip Code
Phone:~~'~~' .~; ( ~`~ '~ G~ `~ ~~ '~l~ ;~:J - ~~ 7 ~ ~~l ~ ~~K''~%/~~ L~jC~( c~~ /Z~ , E~.. ~~
Home Work Fax Email address
(Please check one): I am ow a resident of: North Beach ^ South Beac ^ Middle Beach C~
Business Name: <<eir~ ~?:S~/1--~ ~;' ~G`i~~J A licant's Position: ~"~ '
~- ~~ _ ~!'
Address: t~=~ L? ~~~ `\~f - ~~~7~~J ,1~~ lj ~ -~-~ (~J)
No.
Street
City
State Zip Code
Owner ^ Stockholder/Shareholder ^ Corporate Officer ^ Other Explain:
Professional License (describe~~jic..~~/("'~/ ~'"?~ r~.t ~~~/ r' ~ ,~/1C ref
Attach a copy of the license liste a
1 . Have you ever been convicted of a felony: Yes ^ or No~lf yes, please explain in detail:
Expires:
2. Do you currently have a violation(s) of City of Miami Beach codes: Yes ^ or No,~lf yes, please explain in detail:
3. Do you currently owe the City of Miami Beach any money: Yes ^ or No
If yes, explain in detail:
__
4. Are you currently serving on any City Boards or Committees
If yes; which board?
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 in, which are located within the City of Miami Beach:
~v~s~ 3~a~~oy
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I am now employed by the City of Miami Beach: Yes ^ or No ~ If yes; which 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):
Please list your preferences in order of ranking (1 J first choice [2] second choice, and [3] third choice. Please note that only
three (3j choices will be observed by the City Clerk's Office.
(Regular Boards of City)
^ Art in Public Places Committee ^Housin Authorit
^ Barrier Free Environment Commi»ee ^Loan Review Commi»ee*
^ Beach Preservation Board ^Marine Authority *
^ Beautification Committee ^Miami Beach Cultural Arts Council
^ Board of Adjustment (Flood Management * ^Miami Beoch Commission on Status of Women
^ Bud et Adviso Committee ^Miami Beach Florida Sister Cities
^ Committee on the Homeless ^Normand Shores Local Gov. Nei hborhood Im rovement
^ Committee for Qualit of Education in Miami Beach ^Norfh Beach Youth Center Oversi ht Commi»ee
^ Community Development Advisory Committee* ^Oversight Committee for General Obligation Bond
^ Communit Relations Board ^Parks & Recreational Facilities Board
^ Convention Center Advisory Board ^ Personnel Board *
^ Debarment Commi»ee ^ Planning Board *
^ Design Review Board * ^ Police Citizens Relations Committee
^ Fine Arfs Board ^ Production Indust Council
^ Golf Adviso Commi»ee ublic Safet Adviso Commi»ee
^ Health Adviso Committee ^ afe Committee
^ Health Facilities Authorit ^ Trans ortation & Parkin Commi»ee
^Hispanic Affairs Committee ^ Visitor & Convention Authority *
^Historic Preservation Board * ^ Youth Center Advisory Board
*Board Required to File State Disclosure form
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:
Child's name:
Age: Program:
Age: Program:
This section is "not required" but desired: Age: ^ Gender: Male or Female ^
Ethnic Origin (Check one)
White ^ African-American/Black ^ Hispanic: ^
Asian or Pacific Islander ^ American Indian or Alaskan Native ^
Employment Status: Employed ^ Retired ^ Home-maker ^ Other ^
"I hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by
Chs~~t~~-~; ArtP'de`VII - of the City Code "Standards of Condit for City ers, Employees and Agency
~- /"
~= -_._~embers.
---_..
__ _ - -!' ,ice/S--/C~,~ ~ ~'~...~-I ,~ ~s- ~ L---,
n s ignature Date Name of Applicant (PLEASE PRINT)
Attachment: Please attach a copy of your resume to your application.
NOTE: Applications will remain on file for a period of one (1) calendar year.
Received in City Clerk's Office '~ ~ ~ by ~~ -:''~~~~ ~--~-~.~,,,,,_~ Deputy Clerk
Document Control Number (Assigned by e City CI 's ffice) -~ Revised 1 1 /15/05
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