Jonathan Groff 12/31/2011m M,IAMBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami
OFFICE OF THE CITY CLERK, Robert Parcher, Ciy Clerk
Tel: (305) 673-7411, Fax: (305) 673-7254
12/8/2009
Jonathan Groff
4294 Nautilus Drive
Miami Beach, Florida 33140
Debarment Committee
Florida 33139
- Congratulations! You have been reappointed by Com issioner De ode Weithorn
to the above referenced agency, board or committee for a term endin I: 12/3112011.
If you are unable to accept this appointment, please
(305) 673-7411.
Please read the enclosed material carefully. Again,
Sincerely,
1~~ ~~~-f'
~~u4
~ S~
Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
Gus Lopez
ATTACHMENTS:
Letter of Appointment
Oath
City Code Ordinance section, applicable to agency, board or cc
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
City Wide Permit Application - (Parking Department Form)
Booklet -Guide to the Sunshine Amendment and Code of Ethic
Employees
the City Cl~~k's Office at
ulations an' good luck.
littee
Code of Eth cs Ordinance
for Public Officers and
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
OFFICE OF THE CITY CLERK, Robert Parcher, Cily Clerk
Tel: (305) 673-7411, Fax: (305) 673-7254
TO Jonathan Groff
RE: Debarment Committee
I do solemnly swear or affirm to bear true faith, loyalty and allegiance to the
United States, the State of Florida, and the City of Miami Beach, and to pert
a member of the above-mentioned board or committee of the City of Miami
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 Coc
and Code of Ethics Ordinance), as well as theF/orida Commission on Ethics
Amendment and Code of Ethics for Public ~cers and Emp/ogees, and unde
of a City of Miami Beach Board and/or Committee, I must comply with the fi
ments of Miami-Dade County or the State of Florida (depending on the boa
I serve) on July 1st, following the closing of the calendar year on which-I-ha
Sworn to and subscribed before me this ~ day
*Please visit the City of Miami Beach website at www.miamibeachfl.gov under City
for additional information regarding the Financial Disclosure Requirements.
Florida 33139,
emment of th
all the duties
;h to which I I
(Conflict of In
side to the Su
and that as a
uncial disclosure require-
or committee o which
N!/~i~ .god n
n-
Prieto
Clerk
lerk/Board and mmittees
We are committed ro providing excellent public service and safety to all who live, work and play in o~r vibran-, tropical, historic community.
m MIAMIBEACH
NAME: ~~
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HOME ADDRESS: ~
Apt
PHONE: ~S- ~e
Home
Business NaCm~e:,~'~
Address:
`~i„'s.....12L
House No./Street
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CITY OF MIAMI BEACH
BOA D AND COM ITTEE APPLICATION FORM
First
ass-~
~~ 1
r'a I~O~ton:
Mir~d~~-dle
I'~l.
City State Zip Code
TlGrvff~ K,is~r~~ra~d~'.ro ~X' • eo,w~
.N yC 1l!/a ~ /
No. Street Ciiy State Zip Code
Professional License (descrbe) lid ~~~ ~O//o/A / Expires: r Attach a copy of the license./
I
Pursuant ~ City Code section 2-22(4) a and b: Members of agenaes, boa s, and co shall be affiliated with the city; this
requirement shall be fulfilled in the following ways: a) an individual shall h ve been a reed ant of •ire aty for a minimum of six
months; orb) an individual shall demonstrate owneret-ipfrrterest for a minimu of six months in ~ business established in the aty.
• Resident of Miarrri Beach for a minimum of six (6) months: Yes1~r No U
• Demonstrate an ownershipfinterest in a business in Miami Beach for a min' um of six (t3) mo s: Yes U or No U
• Are you a registered voter in Miami Beach: Yes t~or No ~
• (Please ci a one): I am now a resident of. North Beach South M ~ die
• I am applying for an appointment because I have vial~li~ies, knowle and xperience. Please list below: (j v t/ Zo yle
~ld:.~ r ~ v~r ®.~ /,~,~/..~..~iul~""" a~~~ pp~,~ r ~~o ~rr~o ,~ firrr~r
• you press y a regstered I~yist Hnth the ity o iami Be ~Ves U or No A~
Please list your preferences in order of ranking [1] first choice [2] second cho' ,and [S] third ice. Please note that only three (Sl
choices will be observed by the Clty Clerk's Office. (Regular Boards of City)
U Affordable Hous Adviso Committee ^ Hous o '
D Art in Public Placres Committee ^ Loan Re 'ew Committee
^ Beautification Committee ^ Marine
^ Board of Ad'ustment' ^ Miami ach Commission r Women
^ Bud t Advi Committee ^ Miami ach Cultural Arts ~ ounal
^ Ca ital Im vements Pro'ect;s Ovens ht Committee ^ Miami ach Sister Cities ro ram
^ Committee on the Homeless ^ Norrrat Shores Local ' vemment Nei h. Im rovement
^ Committee for Qual' Education in MB ^ Parks d Recreation Faa 'rties Board
^ Commun' Develo ent ^ Personn I Board
~ Commurt' Relations Board D Planni Board'
^ Convention Certber Adviso Board ^ Polioe 'ins Relations mmittee
barment Committee D Produdi Indu Cou I
^ Des n Review Board' ^ Public Adviso Co ' mittee
^ Oisabil' Axes Committee ^ Safe mittee
^ Fine Arcs Board D Sin le F mil Residential . eview Panel
^ Ga Lesbian Bisexual and Tran ender GLBT ^ Sustai 'I' CommiUee
^ Gott Adviso Committee ^ Tra Reliabil' & Axounfabil' Committee "TRAC"
^ Heathh Adviso Committee p Tra Lion and Paritin ' Committee
^ Health Faalities Autho ' Board ^ Vistor a d Convention
^ Hi nic Affairs Committee ^ V1fa Protection C itbse
^ Historic Preservation Board ^ Youth nter Advi ' rd
I
'Board R ulred to Fite S ' te Disclosure Form
Note: If applying for Youth Advisory Board, please indicate your affiliation with Scott Rakow Y uth Center.
1. Past service on the Youth Center Advisory Board: Yes U No u Years of Servi
2. Present participation in Youth Center activities by your chiMren Yes No . ff yes, please 1' the names of your children, their
ages, and which programs. List below:
Child's name: Age: Program:
Child's name: Age: program;
'r:\CtER\$ALL\aFORMS\BOARD AND COMN;iTTEES\BC Appiication062609 NEW.doc
'*••r .Have you ever been convicted of a felony: Yes u or No'd' If yes, pleas explain in
. Do you currently have a violation(s) of City of Miami Beach codes: Yep U or No Ullf yeas, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes U or N If yes, expt Iin in detail
• Are you c ently servin on any City Boards Committees: Ye~i or No u. If yes; i ich board?
A~ o1/N~svt7` O i . ~i°
• What o iz ti ns in the City of Miami Beach do you currently hold embership in?
Name: D Q»f'~ ~7l/y1~/./~ Title: t/~~
Name: Title:
• List roperties owned or have an interest in, whi are located with n the City of Mi ~mi Beach:
~~f~vfC~l~ ~/s~~l~ Gy~///
~ .
• I am now employed by the City of Miami Beach: Yes U or N ich department?
• Pursuant ~ City Code Seaton 225 (b): Do you have a parent U, spouse U child U, brother U!! or sister U who is employed by the
City of Miami Beach? Check all that apply. Identify the departmerrt(s): /f/~
The following information is voluntary and is neither part of your application nor tra any bearing on ~ ur consi~ratbn for appointment. K is
being asked to comp) with federal equal opportunity n~ortirrg requirements.
Gender: ale ^ Female
E~Ipi'c Origin: Check one only (1)
rte (Not of Hispanic Origin): All persons having origins in any of the original peo les of Europe, NorlhiAfrica or the Middle East
^ African-AmericanBlack (Not of Hispanic Origin): IW persons having origins in an of the Bladr n~cial ~roups of Africa.
i
^ Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish flare or origin, regardless of race.
^ Asian ar Padfic Islander: All persons tmving origins in any of the original peoples the Far East, east Asia, the Indian Subcontinent, on
the Padfic Islands. Thy area includes, for example, Chirp, India, Japan, Korea, the ilippine Is~rrds a ~ Somoa.
^ American Indian or Alaskan Native: All persons having origins in arty of the orig' i peoples of NoRh America, end who maintain
Cultural identification through tribal affiliation or community recognition.
Yes U or
Employment Status:
Retired ^ Homemaker ^ I Other ^
NOTE: N appointed, you will be required m follow certain laws
These laws Include, but are not limited to, the following:
o Prohibition from directly or indirectly lobbying city personnel (Miami
o Prohibition from contracting with the city (Miami-Dade Courrty Code
o Prohibition from lobbying before board/oommitree you have serve
Beach City Code section 2-26).
o Requirement to disclose certrrin financial interests and gifts (Miami-I
(re: CMB Community Development Advisory Commitbae): prohibiti
from having any interest in or receiving any benefd from Commur
or those with whom you have business or immediate family ties (CF
Upon request, copies of these laws may be obtained from the Clty t
"1 here attest m cy and truthfulness of the application
Artlde -oft hY C etandards of Conduct for City Officers,
~/ ~ -
~~
Please attach a copy of your resume to this application
NOTE: Applications wfp remain on file for a
apply b dty ba
rack City Code s
action 2-11.1).
on for period of
ide County Code
t, during tenure
y Development 8
570.611).
erk.
have received,
ployees and Agr
Tdna~a
e of Applicant (PLE
of one (1) calends
Received in the City Clerk's ONios by : Oahe: ~ j!~ Control I
Name of Deputy Berk
members.
2-459).
year after leaving office (Miami
lion 2-11.1).
for one year after leaving office,
c Grant funds for either yourself ,
and will abide by Chapter 2,
Members:'
~/D ,~G
year.
Date: / 1~0