Dina Dissen 12/31/2011MIAMI BEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachA aov
OFFICE OF THE CITY CLERK, Robert Parcher, Ciy Clerk
Tal: 1305) 673-7411, Fox: 1305) 673-7254
2/22010
Dina Dissen
2474 Praire Ave
Miami Beach, Florida 33140
UBJECT^ Police Citizens Relations Committee
Congratulations! You have been reappointed by Commissioner Jerry Libbin
to the above referenced agency, board or committee for a term ending: 1 2131 /2 01 7.
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, /~
Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
Chief Carlos Noriega
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 ro providing excellent public service and safey to oll who live, work and play in our vibrant, tropical, hisroric communiy.
m MIAMI BEACH
City of Miami Beach, 1700 Convenfion Center Drive, Miami Beach, Florida 33139, www.miamibeachA.aov
OFFICE OF THE CITY CLERK, Robert Percher, Ciy Clerk
Tel: (305( 673-7411, Fax: (305( 673-7254
TO Dina Dissen
RE: Police Citizens Relations 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 pertorm all the duties of
a member of the above-mentioned board or committee of the City of Miami Beach to which I have
been appointedforaterm 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 EtlricsGuide to the Sunshine
Amendment and Code of Ethics for Public Ofncprs 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.
~~~~
Dina Dissen
Sworn to and subscribed before me this ~'~day~of , 20~.
Silvia Prieto
Deputy Clerk
*Please visit the Gty of Miami Beach website at www.miamibeachFl.govnnder Gty Gerk/Board and Committees
for additional information regarding the Finandal Disdosure Requirements.
We are commilfed b providing excellent public service and wfey to all who live, work and ploy in our vibraN, tropical, hisbric communiy.
NAM°: ~iss~~
CITY 7F MIAIJI{ 3EAC H.
AND CJMMi T TEE APPLICATIrJN FCF:M.
Las!GNam~e ^ n --~ !-ins; Nams
HDME ADDRESS: "~7v i~ rn e- l(•8-~- t J C
Ap; No. House No./Srreel
PHONE:
35~
Hom fery __ ff work ~~ ~~,~+ Fax
Business Name: ~D'~T 1/1ow. ~ ~~ ttf IA ~A r.~.- Position:
Address: tO5 ~ ~1- ~- IBS ~ S-5 .
Na. Street C
Professional License (describe)
adoress
~~~
Cou.
~~
Expires: Attach a copy or the license
Pursuant m Ctty Code section 2-Z2(4) a and b: Members of agencies, beards, and committees shall be affiliated with the city; this
requirement shall be fulfilled in the following ways: e) an individual shall have been a resident of the city for a minimum of six
months; or b) an individual shall demonstrate ownershiplinterest for a minimum of six months in a business establishetl in the city.
• Resident of Miami Beach for a minimum of six (6) months: Yes D or No D
• Demonstrate an ownershiplirderest in a business in Miami Beach for a minimum of six (6) months: Yes D ar No D
• Are you a registered voter in Miami Beach: Yes D or No D
. (Please circle one): I am now a resident of: North Beach ISoufh Beach Middle Beach
• I am applying for an appointment because I have spsdel abllfties, knowledge and experience. Please list below:
. Are you presently a registered lobbyist with the City of Miami Beech? Yes D or No ^
Please list your preferences in order of ranking [1] first choice [2] second droice, and [3] third choice. Please note that onN three f31
eholtres will be observed by the City Clerk'e Office. (Regular Boards of Ctty)
D Afiordeble Housin Advis Committee D Housin Autho
D Art in Public Places Committee ^ Loan Review Committee
Beautlfic~ion Commltme ^ Marine Aufho
D 8oisrd of 'ustrrrertt' D Mimrri Baach Commission for Women
D Bu Aiivia Commitlee D Miami Beech Guttural Arts Ccundl
D C ifel Im rtfa ectb Ovens' ht Committee D Miami Beach Sister Cttias P
p Committee an the Homeless D Norman Shores Local C3ovammerrt Ne' h. fm rovemerrt
D Committee for 11ua1 Education in MB D Parks and Recreation Facilities Board
^ Commun Develo ment Advieo D Personnel Board
D Commun Relations Board ^ Plennin Board'
^ Gonverrtion Csrrter Advil Board Police Cif~ns Relations Committee
D Debarment Committee ^ Pi~ltution Intl Council
^ Desitm Review Board' ^ Public 5 Adviso Committee
D Disabll Access Committee D Sa Commfttee
Fine Arts Beard D Si k Faml Residential Review Panel
D Ga ,Lesbian. Bisexual and Trans nder GLB ^ Statainabil Committee
^ Golf Advis Committee D Transparen Reliebil & Acmunfabilfty Gommtttee TRAC'
^ Health Adviso Cammtttee D Tre ortation and Parkin Commfttee
D Heatlh Facittfias Auth Board p Visitor and Convention Auth
D His nic Affairs Committee ^ Watertiortt Protection Committee
I ^ Historic Preservation Board D Youth Center Adviso Board
"BoardRequired to Flle State Disclosure Farm
Note: If applying for Youth Advisory Board, please indicate your affiliahon with the Scoh Rakow Youth Center
1. Past service on the Youth Center Advisory Board: Yes . No =~ Years of Service.
2. ~resen+. participation in Youth Center acBvibes by your children Yes_ Nc _. If yes, please list the names of your children, their
ages, end which programs. Lis below
Child's nom=_-
Cnild's name
Age: Program.
Ha°- orogram~
~.!oP.5 A!: ~or~RM,$\B~4P,C 4NC ~OMMII7:E \8: Aooi¢anonOG260° N°_H'.do:
.-lave yo~_ eve' :,_er ca-w:aer a i_iur~: "e=_ -r No :' "as alease exatain Ir aetair.
• .'~a yaU currently' nave e vlaationtsi o' CItY of Nnam~ Beacr~, cedes Yes .. a No I` vas ~ aisase erolalr Ir aetai'.
• Do you currently owe the amity o' IJliam, B=_ach env money Yes . or No -:. I` vas exolarn Ir. detail
• Are you currently s=ruing or anp ~rt~ 3oards ~; ~ommltt=es Yes ar No ". I` vas w~lcr ooard~
• VJhat organizations c. the Cip of Miami Beach oc you currently polo memoersnlF.
Name. _. -itle ...~
Name'
Title: `
• List all properties owned or have an interest in, which are located within,trt~ salty of Miami Bsach
• I am now employed by the City of Miami Beach: Yes G or No^. Which~partment?
• Pursuant to City Code Seefion 2-25 (b): Do you have a parent C, spou _, child C, brother D, or sister ^ who Is employee ay the
City o` Miami Beach Check all that apply. Identify the department(s):
The following information Is voluntary end Is neNher part of your
oeing asked to comply with federal equal opportunity reporting n
nor has any bearing on your eonsitleradon for eppolntmen: 1', ~r
Gender: ^ Ntaie ^ Female
tatnmc ungtn: Vheok on=_ only (1) ~
D White (Not of Hispanic Oripinj All persons having origins in y of the original peoples of Europe, North Afrtea or the Middle East.
^ African-American/Black (Nat of Hlepenfe Origin): Alt pe having ongins m any of the Siaek reaal groups of Africa.
Hispanic: All parsons of Meziwn, Puerto Rkan, Cuban, ttlr'al or South Ametiean, or other Spanish culture or origin, regerdteas of ;ace
^ Aafan or Paelfic kiendar: All paeaons having origins ' ny of the original peoples of the Par cast, SoNheast Axis, the Indian Submnfinem.. or
the Paelfic lslantle. This area hrdutles, for maltiple, ~ 8, India, Japers, Kprez, the PMlippine tstands end Somoe.
^ Amedeen indlan or Aledcan Natlve: All parsons rig ongins in any of the origfnel peoples of North America. and who meiraein
Culaasl iderttificBHon tirtough trmal atNlfelMn or reeopngion.
Physiraliy.Chaliettgad: Ves ^ or NoD
Employment Status: employed p R 'red ^ Homemaker ^ Other 0
NOTE: if appoitrted, you will be aired iD follow certain taws which apply to city boardfeommitlae membaw.
These tears include, but are n Ilmll®d te, the following:
I
~ c Prohibition from directly o indirectly lobbying citi)~ personnel (IVtlam~ Beach. City Code section 2-459)
' Prohibition from co g with the dh' (Miami-Dade County Code saglon 2-11.1)
I o Prohibition from fob g before boartl/commtttee you have served on for period of one year attar leaving office fMlam
Bsach City Code n 2-26).
v Requirement to disc certain financial inte2sts ono grfts (Mtam~-Datle County Cotle section 2-11.1 }.
(re: CMB Commun Development Advisory Commfltee) prohibition, during tenure and for one year after Issuing offce
I from having any irterest in or receiving any benefit from Community Development Block Grant funds for etltler vourset°
or those with whom you have business or immediate family ties (CFR 57D.611).
Upon request, copies of these laws may be obtained from the City ClerY..
"I Hereby attest to the accuracy and truthfulness of the application and have received, read enC wttl abide by Chaote~
Artiyle VIYV -^Ity Cotle "Standards of Contluet for Clty Officers, Employees arid Aoertcy Mamben;."
Applicant's Signature v e Na of HpphCan! (PLcp,Sc pRIN'r;
°lease atrHCh a copy o! your resume [n tnls eppllaehon
N6TE: Appkcafions will remain oc file for a person of one f1 i carenaer veer
Recewec ir. the Cny ~ienrs Gffice oy Ga[= _ ;ZOafr :.omro' No Gale _,"
Name p' Geoutc Olerv.
M®~
SOURCE OF INCOME STATEMENT
Please Print or Type First Name Middle Name/Initial Last Name
Disdosure
' For Tax Year
Name: R v ~ 15SEr~ Ending: ~q
Mailing Address: ~ r~.ti ~~, -L_
city/State/L'p: M-~ ~ ~ ''31 J
Sodal Searrlty Number:
Fling as a: ® County Employee:
® Munidpal Employee of:
Position held or sought:
Board where serving:Poll I,Y~ ~/,,zM ~q ~~ Term or Emplo ~t
Began on: b<{
Departrnerrt where employed:
Work Address:
It your home address bi exempt from public records pur6vaM to
O
florida Statubss § 139.07 please eherk here (read IneWCiions):
Work Telephone:
Home Address: ~ ~~f ~(Zl (nom ~~
Street Address
City State Zip Code
Please list below in descending order with the largest source first, the name, address and
prindpal business ad9vity of every source of your Income induding public salary you
received or arty person received for your benefit or use during the dkcllogure period. The
(noome of your spouse or any business partner need not be disdosed. If continued on a
separate sheet, check here:
Description of the Prindpal
Name of Source of Income Address Business Ad3vl
G ~ S~ ~ .,
I hereby swear (or afFirm) that the aforesaid
nfo
mation is a true and wrrect statement.
(
>
Signature of person disdosing p~ i ~