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Jeanette Egozi 12/31/2011~''~ m Mi..AIUtI ~F_..~~H, City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl aov OFFlCE OF THE CITY CLERK, Robert Parcher, Ciry Clerk Tel: (305) 673-7411, Fax: (305) 673-7254 02-12-2010 Jeannette Egozi 7320 Gary Ave Miami Beach, Florida 33141 SUBJECIT;;;~ Safety Committee Congratulations! You have been appointed by Commissioner Michael Gongora 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 enclosed materials carefully. Congratulations again and good luck. Sincerely, 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 are committed ro providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community. m MIAMI BEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, vvwvr.miamibeachfl.aov OFFICE OF THE CITY CLERK, Robert Parcher, Ciy Clerk Tel: 13051 673-7411, Fax: (305) 673-7254 TO Jeannette Egozi 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 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 Cade of Ethics for Public OhScers 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 Flodda (depending on the board or committee on which I serve) on July 1st, following the closing of the calendar year on which I have serve5t!-'- 1 Jeannette Egozi ~~ Sworn to and subscribed before me 's day of ~~N 1, 20~~ ~_c_ ~% Silvia Prieto Deputy Clerk *Please visit the Gty of Miami Beach website at www.miamibeachFl.govundet City Clerk/BOard and Committees for additional information regarding the Fnancial Disclosure Requirements. We are commiHed to providing excellent public servrca and sofety to al! who live, work and ploy in our vibrant, tropical, historic community. ~~ NAME: HOME ADDRESS: ~ ~fJ a" J (Apt No. PHONE: r..~ ~) ~~ Business Name: Address: ~ Professional License (describe) House Street Fax Position: ~i~fY c~~ ~1~1 ~r~~Ef ~~nt~~s~~ ;~~~i,,l~~ rltf~ ~~~ /~ Zip Cotle a coyy nt t'~o licernsc~ Pursuant to City Code section 2-22(4) a and b: Members of agencies, boards, and committees shall be afFlliated 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 for a minimum of six months in a business established in the city. • Resident of Miami Beach far a minimum of six (6) months: Yes ~ or No ^ • Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes 0 or No ^ • Are you a registered voter in Miami Beach: Yes 0 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 experience. Please list below: • Are you presently a registered lobbyist with the City of Miami Beach? Yes 0 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 (31 choices will be observed by the Citv Clerk's Office. (Regular Boards of City) ^ Affordable Housin Adviso Committee ^Housin Authorit ^ Art in Public Places Committee ^ Loan Review Committee ^ Beautification Committee ^ Marine Authori ^ 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 ^ Communi 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 Safe Adviso Committee ^ Disabili Access Committee afe Committee ^ Fine Arts Board ^ Sin le Famil Residential Review Panel ^ Ga ,Lesbian, Bisexual and Trans ender GLBT ^ Sustainabili Committee ^ Golf Adviso Committee ^ Trans aren Reliabili & Accountabili Committee "TRAC" ^ Health Adviso Committee ~ ^ Trans ortation and Parkin Committee ^ Health Facilities Authorit Board ^ Visitor and Convention Authori ^ His anic Affairs Committee D 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 YesJ No ~. If yes, ages, and which programs. List below: Child's name: Age: Program, Child's name: please list the names of your children, their Age: Program: F:\C1ER~$A11laFORMS\BOARD AND C.CM,V,=iTEES\3C ApplicaiionOF2664 h'EW.doc .Have you ever been convicted of a felony: Yes ^ or No17 If yes, please explain in detail: • Do you currently have a violation(s) of City of Miami Beach codes: Yes D or No f~lf yes, please explain in detail: • Do you currently owe the City of Miami Beach any money: Yes ~ or Nt~ If yes, explain in detail • Are you currently serving on any City Boards or Committees: Yes 0 or No~ If yes; which board? • What organizations in the City of Miami Beach do you currently hold membership in? Name: Title: Name: • List albproperties 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 Nod Which department? • Pursuant to City Code Section 2.25 (b): Do you have a parent ^, spouse q, cftl~d ~rother a, or sister o who is employed by the City of Miami Beach? Check all that apply. Identify the department(s): ~1V) The following information is volunta and is neither part of your application nor has any bearing on your wnsideration for appointment. It is being asked to comply with federa~ual opportunity reporting requirements. Gender: ^ Male Origin: Check one only ^ White (Not of Hispanic Origin): All persons having origins in any of the original peoples of Europe, North Afdca or the Middle East. ^ African-AmericaNBlaek (NOl of Hispanic Origin): All persons having origins in any of the Black racial groups of Africa. All persons of Mexican, Puerto Rican, Cuban, Central or South Amedcan, 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 Nativa: All persons having origins in any of the odginal peoples of North Amedca, and who maintain Cultural identification through tribal affiliation or community recognition. Physically Challenged: Yes q or NOD. 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 intlirectly 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. attest to the - of the City and truthfulness of the application and have received, read and will abide by Chapter 2, indards of Connd1uct ffr City Officers, Emplo(y~ggB'and Agency Me ers." ~ LI~~~I~ 1/, innl ~~s ~f~~71~ Received in l~e City Clerk's Office by : ~ _~i~.r!/ rr livcGCn Date: _/ /2009 Control No. Z ~7~1 v lease Print or Name: Mailing Address: City/State/Zip: Social Security Number: Filing as a: Disclosure For Tax Year Ending: '), ., q Position held or sought: Su~~. ~U~~R\\~~ \-~l`M~ Board where serving: S~ ~,~ /~ ~~~ ~.~, Tenn or Employ ent l Began on: ~~ Department where employed: h~ Work Address: ~-1l ~ ~ ~ rp n ~~ /~ v-~ /~ u ~I~L T S~ ~/~~~ 7 If your home address is exempt from public records pursuant to 3~S_ c, ~ ~ ~` y Florida statutes § 119.07 please check here (read Insbvctlons): ~ Work Telephone: l J Home Address: Street Address City State Zip Code Please list below in descending order with the largest source first, the name, address and principal business activity of every source of your income including public salary you received or any person received for your benefit or use during the disclosure period._The income of your spouse or any business partner need not be disclosed. If continued on a separate sheet, check here: 0 Name f sou In me Ad ress Description of the Principal Business A vl a ni~ (or affirm) that tl foresaid information is a true an correct statement. ~1 ~~ rson disclosing D signed ~ County Employee: ® Municipal Employee of: