Carol Housen 12/31/2011m MIAMI BEACH
City of Miami Beach, 1700 Convention Canter Drive, Miami Beach, Florida 33139, vrww.miamibeachfl.aov
OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk
Tel: 1305) 673-7411, Fax: 13051 673-7254
11 /10/2009
Carol Housen
7330 Ocean Terrace #2001
Miami Beach, Florida 33141
Fine Arts Board
Congratulations! You have been reappointed by Commissioner Deede Weithorn
to the above referenced agency, board or committee for a term ending: 72/3112011.
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,
~~~s~
Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
Gary Fanner
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 commined ro providing excellent public service and safety ro all who live, work and play in our vibrant, tropical, historic community.
m MIAMI BEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachA aov
OFFICE OF THE CITY CLERK, Robert Percher, Ciy Clerk
iel: 1305) 673-7411, Fax: 1305) 673-7254
TO Carol Housen
RE: Fine Arts Board
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/orida Commission on Ethics Guide to the Sunshine
Amertdmentand Code offthics 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 committee on which
I serve) on July 1st, following the closing of the calendar year on which I have served.
~~
,~yyCarol Housen
Sworn to and subscribed before me this /day o~f ~ _- 0 ~ , 200
Silvia Prieto
Deputy Clerk
*Please visit the City of Miami Beach website at www.miamibeachFl,gov under Ciry gerk/Board and Committees
for additional information regarding the Financial Disclosure Requirements.
We are committed ro providing excellent public service and safey ro all who live, work and play in our vibrant, tropical, hisroric communiy.
m !~i`{h.h!`i BEACH
NAME:
HOME ADDRESS:
House
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Address: ,Q-d/Jn-~ L2'.d 2I.C~'r'-~~
No. _ Street
Professional License (describe)
I CITY OF MIAMI BEACH
COMMITTEE APPLICATION FORM
~/Y'OS( ~QS~ •awm riy ~.v~c
Expires:_~ D / 3Arach a copy of the license
Pursuant to City Code section 2.22(4) a and b: Members of agencies, boards, and committees sFiall be affiliated with the city; this
requirement shall be fulfilled in the following ways: a) an individual shall have' been a resident of the dty for a minimum of six
mordhs; orb) an individual shall demonstrate ownership/interest f``or''a minimum of six months in a business established in the city.
• Resident of Miami Beach for a minimum of six (B) months: Yes,H`er No ^ ~
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months:~Yes~7 or No ^
• Are you a registered voter in Miami Beach: Yes ^ ~Z12-tM. t~.2~ rt(.2~t' _ Qd~wR.aQ,~~ G~
. (Please arcle one): I am now a resident at orth Beac South Beach Middle Beach
• I am ap ing for an appom ant bepuse I ha specie a ili~ti~s kngwled a end expedence. Please list below:
~o o d ~-.~?~- '~~+~rc.. '- 1YG IURS'~
• Are you presently a registered lobbyist with the City of Miami Beach? Yes ^ or N~
Please list your preferences in order of tanking (1J first choice [2) second choice, and [3] third choices Please note that only three f3)
choices will be observed by the CIN Clerlt'e Office. (Regular Boards of City)
^ Affordable Housin Adviso Committee D Housin Autho ' I
^ Art in Public Places Committee ^ Loan Review Committee
^ Beautifiption Committee D Marine AuCto
^ Board of Ad'uatmenC D Miami Beach Commission for Women.
0 Bud et Adviso Committee ^ Miami Beach Guttural Arts Council.
D C ital Im rovemems Pro ads Oversi ht Committee D Miami Beach Sister Cities P rem
^ Committee on the Homeless D Normand Shores Local GovemmeM Nei h. Im rovement
^ Committee for dual' Education in MB ^ Perks and Recreation Facilities Board
D Communi Develo merit Adviso ^ Personnel Board ~ I
^ Commun Relations Board annin Board' I
^ Convention Center Adviso Board D Police Citizens Relations Committee
^ Debarment Committee ^ Production Indu Councl I
esi n Review Board' ^ Public Se Adviso Committee
^ Disabil' Access Committee ^ Sa Committce ; I
ine Arts Board ^ Sin le Fami Resiiierrtial Review Panel
^ Ga ,Lesbian, Bisexual and Trans ender GLBT D Sustainabii Committee I
^ Golf Adviso Committee ^ Tren aren Reiiabil & Arcountebil Committee 'TRAC"
^ Health Adviso Committee ^ Tren ortation and Parkin Committee
0 Health Facilites Autho ' Board D Visitor antl Converdion Autho ' '
^ His snit Affairs Committee ^ Waterfront Protection Committee
^ Historic Preservation Board D Youth Center Adviso Board I
I
'Board Required to File State Disclosure Form
t
Note: If applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow YouAth Cent f~'
1. Past service on the Youth Center Advisory Board: Yes ^ No ^ Years of Service: ~Il/ 1 r /,
2. Present participation in Youth Center a ities by your children Yesn No C. If yes, please list the names of your children, their
ages, and which programs. List below:
Child's name: ~_ Aae: Program: i
Chiltl's name:
Last
Program:
//
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F:\CLEP.\3ALL\aFCRMS\BC)ARD AND yvMMITTEES\BC Appiication062609 NEW.doc
•Have you ever been convicted of a felony: Ye or No _ If 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 If yes, explain in detail
• Are you currently serving on any Cif Boards or Committees: Yes ~orNo =. If yes; which board?
• What organization/stein t(h~eCity of®Mia/mi Beach do you currently hold membership in?
Name: /V/7 r / ~ /"lC~t~.~r [ )OL~r d /eP Title:
/~ ,
Name: ST ~~h12PZ ~~~ ,J°J/Ir~ino //i~a
• List all propertie owned or have an interest in, which are located within the City of Miami Beach:
~33/J ~~~r ~.~i ~ozoo/ ~o~ /~9cr#_~.,i fir
• I am now employed by the City of Miami Beach: Yes D or N~ Which department?
• Pursuant to City Code Section 2-25 (b): Do you have a parent ~, spouse ~, child ^, brother C, or sister ^ who is employed by the
City of Miami Beach? Check all that apply. Identify the tlepartment(s): y~~
The following Information Is volumary en is neither part of your eppllcadon nor has any treating on your conaltleredon for appointment. It Is
being asked to comply with federal a ,opponunity reporting requlremente.
Gender: 0 Male emale
ttnmc Ongtn: Check one only (1)
White (Not of Hispanic Origin): Alf persons having odgins In any of the original peoples of Europe, Nanh Afdca or the Middle Fast.
^ African-AmericanBlaek (Not of Hispanic Ongin): All persons having Origins in any of the Black racial groups of Afdca.
^ Hfepenle: All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or ongfn, regardless of race.
^ Asian or PacNic Ieiender: All persons having odgins in any of the original peoples of the Far East, Southeast Asia, fhe Indian Subcontinent on
the Padfic Islands. TMs area includes, for erotmple, China, India, Japan, Korea, the PMlippine Islands and Somoe.
^ Amencen Indian or Alaskan Native: All persons having odgins in any of the original peoples of Nodh America, end who mairrtetn
Cultural identification through tdbel afllli nor community recognition.
Physically Challenged: Yes C or No»
Employment Status: Employed ^ Retired ^ Homemaker D Other SO , r~~m~~~~.
NOTE: If appointed, you will be required to follow certain taws which apply to city boardlcommlttee members.
These laws include, but are not limited to, the following:
o Prohibition from directly or indirectly lobbying city personnel (Miami Beach City Code section 2-459).
o Prohibition from contracting with the city (Miami-Dade County Code section 2-11.1). ~ '
o Prohibition from lobbying before boardlcommlttee you have served on for period of one year after leaving office (Miami
Beech City Code section 2-26).
o Requirement to disclose certain financial interests and gifts (Miami-Dade County Code section 2-11.1).
(re: CMB Community Development Advisory Committee): prohibNon, during tenure and for one year after leaving office,
from having any interest in or receiving any benefit from Community Development Block Grant funds for either yourself ,
or those wRh whom you have business or immediate family ties (CFR 570.611).
Upon request, copies of these laws may be obtained from the City Clerk.
"I hereby attest to the accuracy and truthfulness of the application antl have received, read and will abide by Chapter 2,
Article VII - f the Clty Code " tandards of Conduct for City Officers, Employees and Agency Members."
~i /~/a 9 C'Aseoi ~ ~o~.~
Applicerrt's Signature Uat~ Name of Applicant (PLEASE PRINT)
Please attach a copy of your resume to mis application
NOTE: Applications will remain on file for a period of one (1) calendar year.
Received in the City Clerk's Office by : Date: _I /2009 Cornrol No. Date: _I_120p9
Name o/ UepNy CIerK