Jane Hayes 12/31/2011MIAMIBEACH
City of Miami Beach, 1700 Convenfion Center Drive, Miami Beach, Florida.33139, wvrw.miamibeochA.aov
OFFICE OF THE CITY CLERK, RobeA Parcher, Ciy Clerk
Tel: (305) 673-7411, Fax: (3051 673-7254
01-21-2010
Jane Hayes
3001 Prairie Ave
Miami Beach, Florida 33140
S.UBJECTt_ Safety Committee
Congratulations! You have been appointed by Commissioner Jerry Libbin
to the agency, board or committee named above for a term ending: 12/31/2011.
Pursuant to Ordinance No. 2006-3543, commencing with terms beginning on or after
January 1st, 2007, the term of board members who are directly appointed by a member of
the City Commission shall automatically expire on December 31 of the year the appointing
elected official leaves office.
If you are unable to accept this appointment or have any questions, please call the City
Clerk's Office at 305-673-7411. Please read the enGosed materials carefully.
Congratulations again and good luck.
Sincerely,
o~{~ M
~ ~~~
Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
Clifford Leonard
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, 2-458 and 2-459
Ordinance No. 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 Employee
We ore committed ro providing excellent public service and safety ro all who live, work and play in our vibrant, tropicol, historic communiy.
m MIAMI BEACH
City of Miami Beaeh, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.aov
OFFICE OF THE CITY CLERK, Robert Parcher, Ciy Clerk
Tel: (305) 673-7411, Fax: (305) 673-7254
TO Jane Hayes
RE: Safety 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 tc 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 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 ~llale~~dar year on hich I have served.
~d'~~~~~
\ I~ Jane Hay sI^ I !~
Sworn to and subscribed before me~~ day of ~~ , 2001 ~/
Deputy Clerk
'Please visit the Gty of Miami Beach website at www.miamibeachFl.gov under City Gerk/BOard and Committees
for additional information regarding the Financial Disclosure Requirements.
We are committed ro providing excellent public service and salary ro all who live, work and play in our vibrant, tropical, historic community.
T
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NAME: r w' ~'~
Last Name
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Apt No
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CITY OF MIAIJII 3EkCY
BOARG AND COMMITTEE APPLICE,TION FORM
Pi
Initial
.~ 61`t 2 Sots-I I~GLa ~ , ~ tnn
Fax Email a dress
Position: ~CA)ne~ / dY`Oi'(1Ag,Q ~
State
_House
Address:
No Street City State Zip Code
Professional License (tleschbe) ~'('fl •~~ Expires. Attach a copy o(the license
Pursuant to Clty Code section 2-22(4) a and h: Members of agencies, boards, and committees shall be affiliated whh the city, this
requirement shall be fulfilled in the following ways: e) an intlividual shall have been a resident of the city for a minimum of sa
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 s minimum of six (6) months: Yas ^ or No ^
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes ^ ar No
• A2 you a registered voter in Miami Beach: Yes ^ or No ^
. (Please circle one): I am now a resident of North Bsaeh South Beach Middle Beach
• I am applying for an appointment because I have special abilities, knowledge and experience. Pfease list below:
. Are you presently a registered lobbyist with the City of Miami Baach7 Yes ^ or No ^
Please list your preferences in order of ranking [1j first choice [2j second choice, and [3j third choice, Pfease note That onfv three l31
choices will be observed by the City ClerMs Office. (Regular Boards of City)
^ Affordable Housin Advtso Committee ^ Housin Atrthd
D Art in Public Plus Committee ^ Loen Review Committee
^ Beaufffiration Committee ^ Marine Autho
C Board of Ad'ustmerrt' D Miami Beach Commission for Women
D Bud Adviso Committee ^ Miami Beach Cultural Arts Courrdl I
^ C frsI fm vemerrts 'sets Oversi trt Commtttee D Miami Beach Sister Cities P ram
^ Committee on the Homeless D Norman Shores Local Government Nei h. Im rovemerrt
D Committee for Duai Education in MB p Pahts and Recreation Fecllities Board
D Commun Develo errt Adviso ^ Personnel Board
^ Commun Relations Board ^ Ptannin Beard'
^ Convemion Cerrter Adviso Board C Police Citizens Relations Committee
^ Debarment Committee D Production Indu Council
^ Desi n Review Board' ^ P tic 5 Adviso Committee
^ Disabll' Access Committee Sa Committee
^ Fine Aris Board ^ Si le Famif Residarriial Review Panel
0 Ga ,Lesbian, Bisexual and Trans ender GLBT D Sustainabil' Committee
^ Goff Adviso Committee ^ Tre ren Reliahll' & Accoumabii Committee "TRAC'
^ Heatth Adviso Committee ^ Tren artation and Parkin Committee
D Health Faalities Autho ' Board ^ Visitor and Convention Atrtho '
C His anic Affairs Commitce ^ Waterfront Protection Committee
^ Historic Preservation Board ^ Youth Cerrter Adviso Boartl
"Board Required to File State Disclosure Form
Note: If applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Cerrter:
1. Pas service on the Yeuth Center Advisory Board: Yes C No p Years of Service:
2. Presem participation in Youth Center activflies by your children Yes_ No ~. If yes, please fist the names of your children, their
ages, end which programs. List below.
Child's name Age: Program:
Child's name: Age Program:
F'\_LEP•,5A!!\or~RM,S \B74RD AND ~OMMnTE$\B: AcoiicotionOfi2fi09 NEVd.ooc
•~ava you ever poor oorvlct=~ a's ieionS~ Yes
No P vas. aleese explain in de;aif.
- ~~ you currently have a vioiation(sj a City of Miami Beach; nodes: Yes . 'No I` yes
,please exptalr; Ir. detail,
• Do you currently owe the City of Miami Beach any money: Yes = or
~ If yes. explain In detail
• .q re you currently servino or any City Boards or Committees ~/^'~
Y~~ or No -.. If vas- which board
• What organizat' ns in the Ci[ ~ of Miami Be
- S ach tle you currently hold membership In?
Name:
Name: --'-'-- Title: d`~P,YV~~e
Title:
• List all properties owned or have an interest in, w ch are located within the City of Miami Beach:
300\ ~t`n,~to ~.o
• I am now employed by the CRy of Miami Beach: Yes ~ or NofC Which department?
• Pursuant to City Code Seefion 2-25 (b): Do you have a parent ~, spouse _~, child ~ brother ~ or sister D who is employed by the
City of Miami Beach? Check all that apply. Identify the tlepartmerrt(s):
The following intormatfon Is voluntary and Is neither part of your applllatlon nor
being asked to comply with federal equal opponun has any bearin on o r
_ /~ hY reporting requlremerrte g Y u consltleradon for eppofntment, It is
Gender: ^ Maie u't'smale
~-_~.~ -'•arrr~ neck one only (1)
[.+-white (NOi of Hispanic Origin): All persons hevhtg origins in any of fhe original peoples of cu
^ Afrfean-Ameriean/Btaek (Not of Hleparttc Origin): All pergpre having origins in any o` the Bls~ ~~rofdca or the Middle East.
^ HiePanic: All parsons of Maxiean, Puerto Rkart, Cuban. Carmel or South American, or other g g ups of Africa.
.7 Asian or Paclfie islander: All Parsons laving origlrrs in any of the original peoples of the Far - panish culture or origin, regardless of race.
the Pacific Isiantls. This area ktrJUdas, for emmple. Chkt& India, J an, cast, Southeast Asia,
^ American tndten or Alaskan ~ Korea, the PhiilPWne Islands and Sompg, the Indian Subcontinent, or
Cuhural idgrrttfica5on lhreitgh tribal 'All persons having origins in any of the orfginei peoples of North A
afiWation or carrarvtnhy recognition. medea, end who maintain
Physically Challenged: Yes p or Nd6~
Employment Status' Employed Retired ^
Homemaker ^
NOTE tt •....^r~.. --
These taws include, but are not IimMad m~ follow certain laws which apply to city board/committee members.
the following;
° Prohibition from directly or indirectly lobbying ~, personnel (Miami Beach Ci
° Prohibition from corrtrecting with the d(y (Miami-Dade Count tY Code section 2-459).
° Prohibition from lobbying uefore board/committee you have served onttfor period) of one
° R Qu rsmerrt to disclose ~rtaisfinancial interes}s and Ifts Mlam~- „ y~r ~r leaving office iMlam..
(re' CMB Community Development Advisory Commlftee ~ ( Dade ..purity Code aecfion 2-11.1).
from having any interest in or raoaiving any benefit from C mmbunity Deve opmen~Block Grrant funds for either yourself
or those with whom you have business or immediate family yes (CFR 57D.611). Year after leaving office
Upon request, copies of these laws rimy be obtained from the City Cierl;
"I hereby attest to the accuracy and truthfulness of the a
Article 1 } _ of the Clty C deb Standards of Conduct for C ppheation and have received, read and will abide b ~ ^
y~~n1 ' itS' o~fic~etrs. Empioyeas and Agent Mem`bers.•' 1 "hapter ?.
APPii Signawre `~~{,i -riV ~p~-~-'1~ ~ '(~~. ~-IP
Da
pleas rvame of Appacanl (P AS_ pRIN7)
ch a copy of your resume to this apppcetion
NOTE pplications will remain on flf or a period o' one 1
( i calenoar year.
F;ecewec in the City Clen;'c Office op
N e of p a Dat~; /2 0 Control Np Gate
_ ODD
I~~
Please Print or
Name:
Mailing Addre
City/State/Zi{
Social Securit; ___
Filing as a: ® County Employee;
~Niunicipal Employee of: \ \,, -
Pasitian field or sought; ~~,V1 ('~r1~M,M~-T~-~c~
,insure
Tax Yaar
board where serving; M ~ Term or Employment
Hagan on: ~~ ~ ~~ I ~
Department where employed: ~
Work Address;
Sf your home atldreas is exempt from Public records pursuant tv
Florida Steeutec § 17.g.Q7 please ehoek here (road instruedonsj: ® Work Telephone:
Home Address: ~ '~
Streest Address
City
Zip Code
Pisase list below in deso3nding order with the largest source first, the name, address and
principal business activity of every saur~ of your income including public salary yvu
received or any parson received for your benefit or use during the disclosure period. 'fhe
income of your spouse or any business partner need not be disciors~d. If continued on a
separate sheaf, check here; '0
of
N
I hereby swear (or affm,~) thQ~t the aforesaid information is a true and correct statement.
Signatu person die; losing IIate signetl
50URCE OF INCOME STATEMEfYT