Roberta Gould 12/31/2011
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachA.oov
OFFICE OF THE CITY CLERK, Robert Parcher, Ciy Clerk
Tel: (305) 673-7411, Fax: (305J 673-7254
12/8/2009
Roberta Gould
6585 Allison Road
Miami Beach, Florida 33141
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~SUBJECT:_J( Miami Beach Commission For Women
Congratulations! You have been reappointed by Commissioner Deede Weithorn
to the above referenced agency, board or committee for a term ending: 12/31/2011.
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,
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Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
Wanda Ortiz
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 to all who live, work and play in our vibrant, tropical, historic community.
m MIAMIBEACH
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) 673-7411, Fax: (305) 673-7254
TO Robert Gould
RE: Miami Beach Commission For Women
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
Amendment and Code of Ethics for Public OR'rcers 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.
Robert Gould
Sworn to and subscribed before me this ~~day of d U , 20~~D
{~.Silvi 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 safely to all who live, work and play in our vibrant, -ropical, historic community.
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Apt No. House No./Street City St a Zip Code
PHONE: ~.J '~ ~ tj -~-I ,!yJ b °' ~ O - " 3 ~ ~ • C-~
Home Work ~a~wQ ~' Fax Email add (
Business Name: ~ ~V o Position: (`^ ~ c~ t 25 Q~
Address: ~ ~~ ~ ~ ~j ~
No. Street City State Zip Code
Professional License (describe) v~ 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 fod a minimum of six months in a business established in the city.
• Resident of Miami Beach for a minimum of six (6) onths: Yes JJ or No ^
• Demonstrate an ownership/interest in a business i Miami Beach for a minimum of six (6) months: Yes ^ or No ^
• Are you a registered voter in Miami Beach: Yes L 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 and experjence. e~ a ist below:
• Are you presently a registered lobbyist with the City of Miami Beach? Yes ^ or No ^
Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that only three f31
choices will be observed by the City Clerk's Office. (Regular Boards of City)
^ Affordable Housin Adviso Committee ^Housin Authorit
^ Art in Public Places Committee ^ Loan Review Committee
^ Beautification Committee Marine Authorit
^ Board of Ad'ustment* Miami Beach Commission for Women
^ Bud et Adviso Committee ^ Miami 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 Government Nei h. Im rovement
^ Committee for Qualit Education in MB ^ Parks and Recreation Facilities Board
^ Communit Develo ment Adviso ^ Personnel Board
^ Communit Relations Board ^ Plannin Board*
^ Convention Center Adviso Board ^ Police Citizens Relations Committee
^ Debarment Committee ^ Production Indust Council
^ Desi n Review Board* ^ Public Safet Adviso Committee
^ Disabilit Access Committee ^ Safet Committee
^ Fine Arts Board ^ Sin le Famil Residential Review Panel
^ Ga ,Lesbian, Bisexual and Trans ender GLBT ^ Sustainabilit Committee
^ Golf Adviso Committee ^ Trans arenc Reliabili & Accountabilit Committee "TRAC"
^ Health Adviso Committee ^ Trans ortation and Parkin Committee
^ Health Facilities Authori Board ^ Visitor and Convention Authorit
^ His anic Affairs Committee ^ Waterfront Protection Committee
^ Historic Preservation Board ^ Youth Center Adviso 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: Age: Program:
Child's name: Age: Program:
F:\CCER\$ALL\c,FORMS\t3C7ARD AND COMMIETEES\BC AppiicationOb26D~i NEW.doc /
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.Have you ever been convicted of a felony: Yes ^ or No ~Ylf yes, please explain in detail:
• Do you,~tlrrently have a violation(s) of Ciry 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 ^`~If yes, explain in detail
• Are you currently serving on ,Sny City Bolds or Committees: Yes ^ or No ^. If yes;, which board?
• What organizations in the City of Miami Beach do you currently hold membership in?
Name: Title:
Name:
• 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 V`IVhich 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):
The following information is voluntary nd is neither part of your application nor has any bearing on your consideration for appointment. It is
being asked to comply with federal ual opportunity reporting requirements.
Gender: ^ Male emale
Et Ic Origin: Check one only (1)
White (Not of Hispanic Origin): All persons having origins in any of the original peoples of Europe, North Africa or the Middle East.
^ African-American/Black (Not of Hispanic Origin): All persons having origins in any of the Black racial groups of Africa.
^ Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
^ Asian or Pacific Islander: All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, on
the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands and Somoa.
^ American Indian or Alaskan Native: All persons having origins in any of the original peoples of North America, and who maintain
Cultural identification through tribal affiliation o mmunity recognition.
Physically Challenged: Yes ^ or No~~
Employment Status: Employed ^ Retired ^ Homemaker ^ Other ^
NOTE: If appointed, you will be required to follow certain laws which apply to city board/committee 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 board/committee you have served on for period of one year after leaving office (Miami
Beach 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): prohibition, 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 with whom you have business or immediate family ties (CFR 570.611).
Upon request, copies of these laws may be obtained from the City Clerk.
"1 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 A ency Members."
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Applicant's Signature Date 1 ~ ,/Name of Applicant (PLEASE PRINT)
Please attach a copy of your resume to this application Q/1/ ~( /UC
NOTE: Applications w I remain on file or a period of one (1). calendar year.
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Received in the City Cferk's Office by : Date: _/ /2009 Control No. 3 ~ Date: =~, (~ ~ v
Name of eputy Clerk /~
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