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Dr. Baruch Jacobs 12/31/11• m MIAMIBEACH City of Miami Beach, 1700 Convenfion Center Drive, Miami OFFICE OF THE CITY CLERK, Robert Porcher, City Clerk Tel: (305) 673-7411, Fox: (305i 673-7254 1 /15/2010 Baruch Jacobs M.D. 3605 Flamingo Dr Miami Beach, Florida 33140 UB ~: _ Public Safety Advisory Committee Florida: 33 T39 Congratulations! You have been reappointed by Com issioner Ed obin to the above referenced agency, board or committee for a term endin 12!3112011. If you are unable to accept this appointment, please (305) 673-7411. Please read the enclosed material carefully. Again, Sincerely, ~~~~~ s~ Robert Parcher City Clerk cc: Saul Frances, Parking Director Chief Yuhr 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 CI~'rk's Office at :ulations a °d good luck. '~ i~ i ~I ~ittee ~ Code of Ethics 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, -ropical, historic community. r m M,AMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami OFFICE OF THE CITY CLERK, Robert Parcher, Ciy Clerk Tel: (305) 673-741 1, Fax: (305) 673-7254 TO Dr. Barush Jacobs RE: Public Safety Advisory 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 perfc a member of the above-mentioned board or committee of the City of Miami E been appointed for a term ending: 12/31/2011. • Florida 33139, voww.miamibeachH.aov ment of the all the duties of :h to which I have I have been issued a copy of Section 2-11.1 of the Miami-Dade County Cod (Conflict of Interest and Code of Ethics Ordinance), as well as thef/o~da Commission on Ethics vide to the Sunshine Amendment and Code ofEthia' fot-Public Officers and Emp/oye~es, and unde nd that as a member of a City of Miami Beach Board and/or Committee, I must comply with the fi ancial disclosure" require- ments of Miami-Dade County or the State of Florida (depending on the boar or committee on which I serve) on July 1st, following the closing of the calendar year on which I ha a served. ` r arusi~ Jacobs Sworn to and subscribed before me this ~ day Of ~-~ 20~(~ „~~ Silvi Prieto lepu Clerk *Please visit the City of Miami Beach website at www.miamibeachfl.gov under for additional information regarding the Fnanaal Disclosure Requirements. ~Clerk/Board and Committees We are committed to providing excellent public service and safety to all who live, `work and play in our vibrant, tropical, historic community. ,' ~~- ~ ~ NAME: 1 ~~ CITY Oi= MI~,M! BEACH OARG AND COMMITTEE ,4PPLICATION TORN l/ ~j first Name ,/~ / Middle Initial Hous No./S reet City State Zip Code ~ ~o .~~ -~1' .7~.r T ~~~~,u~J~r~.k.u..s.~.~e~~ Hom Work Fax ,n Ema((addres~p~~~,,~ivg~.~-+ Business Name: ~ ~ ~f ce~if) ~T ~ Po Ilion: (/ 6J~,.P~ / Last "I HOME ADDRESS: Apt No. PHONE: ~ ~. 7 ` Address: 7UU l/'!/~~ u~~!~ No. Professional License (describe) _~1Y CL Street City ~, State Zip Code _ Expires: ~~Ii %~0/a gnach a copy of the license Pursuant to Clty Code section 2-22(4) a and b: Members of agencie$, boards, and committees shall be affiliated with the city; this requirement shall be fulfilled in the following ways: a) an individual slhall have' been a resident of the city for a minimum of six months; or b) an individual shall demonstrate ownershiplinterest fora Inimum of six months in a busines~ seta I~~i hsd in the city. Q • Resident of Miami Beach for a minimum of six (6) months: Yes,~'or o D -=a o ~ • Demonstrate an ownership/interest in a business in Miami Be ch for minimum of six (6) months: Yes r Nov" • Are you a registered voter in Miami Beach: Yes or No 0 ~ ~ ~ ..~ • (Please circle one): I am now a resident of: ~orth Beach oath Beach Middle Be .- ,~ • I am applying for an appointment because I have special abilities, kn wledge and expo nce. P list b9iow-- ,' • Are you presently a registered lobbyist with the City of Miami Beach? es 0 or No~. ci: ~ y= G~ Please list your preferences in order of ranking [1j first choice [2] seconds choice, and [3] third choice. Piease~iote fh: choices wtll be observed by the City Cleric's Office. (Regular Boards f City) ~ to ^ Affordable Housin Adviso Committee D H usin Autho ' D Art in Public Pieces Committee ^ an Review Committee D Beautification Committee 0 M tine Autho , ^ Board of Ad'ustmerrt" D M ami Beach Commission for 1Nomen D B Adviso Committee 0 M ami Beach Cultural Arts Councl ^ C ttel im mvemerrts Pro sots Oversi ht Committee D M ami Beach SisterCifies Pro ram ^ Committee on the Homeless 0 N nnan Shores local Gvvemmerrt Nei h. lm rovement ^ Committee for Qual' Education in MB 0 P r'k5 and Recreation Facilities Beard D Commun Develo meat Adviso D P rsonnel Board D Commun Relations Board D Pi nnin Board" 0 Convention Center Adviso Beard 0 P lice Citizens Relations Committee D Debarment Committee 0 P duction indu Council ^ Desi n Review Board" P blic S Advisb Committee D Disabil Access Committee ^ 5 Committee 0 Fine Arts BaarcJ D 5' fe Famit Residential Review Panel D Ga ,Lesbian, Bisexual and Trans ender GLBT ^ S stainabil' Committee ^ Gott Adviso Committee ^ T ns aren Rsliabil' 8~ Accountabil Committee "T'RAC" Health Adviso Committee p T n ortation and .Parkin Committee D Health Facilities Autho Board ^ V' itor and Convention Arrtho ' D His nic Affairs Committee D aterfront Protection Committee 0 Historic Preservation Board D Y uth Center Adviso Board "B and Required to Flie State Disclosure Form Note: If applying for Youth Advisory Board, please indicate your 1. Past service on the Youth Center Advisory Board: Yes ^ No ~ Years 2. Present participation in Youth Center activities by your children Ye ages, and which programs. List below: Child's name: Age; Child's name: Age: F:\: LER\~AL!\aF~RMS~BOARD AND COMMITTEES\BC Applicotion062604 with the Scott Rakow Youth Center: Service: No =. If yes, please li~~th~ ~~es ~ ~ yPJ~~ OIOZ n, their _ Program: _ Program: ~ u `-~ ~ i -~ ~ ,~ .do; scanned •~iave you ever been convicted•felony Yes ~* No 1= v_ es lease expli~ detail: • Do you currently have a violation(s) of City of Miami Beach code :Yes =. o No ~. f yes, please explain in detail: • Do you currently owe the City of Miami Beach any money: Yes . or o ~. if yes. explain in detail • Are you currently serving on ny C' y Bo~rds o Committees: Ye ~or No ".. If yes; which board? ~~ • What organizations in the City of Miami Beach do you currently old membership in? Name: Trti Name: Till • List all roperties owned or have an interest in, which are locate within the City of Miami Beach: DoT ~~-~~~-- • I am now employed by the City of Miami Beach: Yes D or No hich department? • Pursuant to City Code Section 2-25 (bj: Do you have a parent D, spo se C, child C; brother C, 'or sister 0 who is employed by the City of Miami Beach? Gheck all that apply. Identify the department(sj:~a The following information is voluntary and Is neither part of your apptlcatlon or has any bearing on your consideration for appointment. It is being asked to comply with federal equal opportunity reporting requirements. Gender: ale O Female Ethnic Origin: Check one only (1) ~Whlte (Nat of Hispanic Origin): All persons having origins in any of the origin I peoples of Europe, North Africa or the Middle East. ^ African-American/Black (Not of Hispanic Origin): All peceons having origins in any of the Black racial groups of Africa. ^ Hispanic: All persons of Mexican, Puerto Rion, Cuban, Central or South Am titan, or other Spanish culture or origin, regardless of race. ^ Asian or Pacific Islander: All persons having origins in any of the original pe pies of the Far East, Southeast Asia, the inrJtan Subcontinent, on the Padfrc tstarids. This an9a iriduales, for ezampte, China, India, Japan, ICO ,the Phtttppine !stands and Somaa. ^ Amerlcatt tndllan or Alaeken Native: Ail persons having origins in any of the original peaptes of North America, and who maintain Cultural tdentffrcaSon through tribal affiliation or community recognftion. Physically Chatienged: Yes ~] or No . " Employment Status: Employed Retired 0 Homemaker 0 Other ^ NOTE: tf appointed, you will 6e-required to follow certain taws hich apply to city board/committee members. These laws include, but are not 6mttad to, the following: o Prohibition from directly or indirectly lobbying city personnel (M ami Beach City Code section 2-459}. o Prohibition from contracting with the city (Miami-Dade County ode section 2-11.1). o Prohibition from lobbying before board/committee you have s rued on for period of one year after leaving offrce (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 Commun Deveio ment Adviso Committee ~Y p ry ) pro ibition, during tenure "and for one year after leaving office. from having any inbarest in or receiving any benefit from Co munity Development Block Grant funds for either yourself , or those with whom you have business or immediate family tie (CFR 57D.611). ' I .. . Upon retquest, copies of these laws may be obtained from the fty Cleric. ~ ' "I hereb est to the curacy and truthfulness of the appiicatto and have received, read and will abide by Chapter 2. Article - of the C e "Standards of Co uc for City Office pioyees and Agency Members." ~ o ~~ li A 's Signal Uate Name of Applicant PLEASE P N7) Please attach a copy of your resume to this application NOTE: Applications will remain on file fora eriod of one (1) calendar year. Received in the City Clerk's Office by _' t ~ D te0~;~~/ 86~D ontrol No ~' ~~'-f-- Date: ~ ~/' Name of Deputy Clerk ~, };. ,. -.. ,. .,.i _ ..