Scott Robins 12/31/2010/'~.`~,
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OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk
Tel: (305) 673-741 1, Fax: (305) 673-7254
02-02-2010
Scott Robins
1800 W . 24th St
Miami Beach, Florida 33140
~UBJECTe Safety Committee
Congratulations! You have been appointed by Cornrnissioner Ed Tobin
to the agency, board or committee named above for a term ending: 12/31/2010.
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 ®ecember 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,
~1L~~ S ~
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Robert Parcher
City Clerk
cc: Saul Frances, Parking ®irector
Clifford Leonard
Al°TACHMENTS:
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 to providing excellent public service and safety to a!1 who live, work and play in our vibrant, tropical, historic community.
m ~1~11AM!BEACH
City ®f Miarv'i Be®eh, 1700 Convention Center Drive; Miami Beaeh; Florida33139, vvww.miamibeachfl.gov
OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk
Tel: (305) 673-741 1, Fax: (305) 673-7254 -
TO Scott Robins
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: 12/31/2010.
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 calendar
Scott Robins
Sworn to and subscribed before me thi ' d ~ ay of 1~~~"` , 20¢ D
Silvia Prieto
Deputy Clerk
*Please visit the City of Miami Beach website at www.miamibeachfl.gov under City Clerk/Board and Committees
for additional information regarding the Financial Disclosure Requirements.
We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community.
m 1V1IAM1 BE 1~! 1 -^--- - .p^...n04T^CITYOFMIAMI,BEACH
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NAME:
La{st~~Name j~. First Name Middle Initial
HOME ADDRESS: c~ 1~ ~ L ~~~
r~ Apt No, -~-/ House No./Street City State Zip Code
PHONE: _ J b S'" ~~ ~ ~ ~J to C ~ F~ ~ ~ 1 ~7~ ~ ~ ~C~~ i ~
Home
Business Name: C ~
Address:
No.
Professional License (describe) _
tman address
City ~ State Zip Code
_ Expires: A2~tach a copy of tie liceras~
v( ~
Pursuant to City Code section 2-22(4) a and b: Members of agencies, boards, and committees shall be affiliated 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 for a minimum of six (6) months: Yes ~or No ^
. Demonstrate an ownership/interest in a business n Miami Beach for a minimum of six (6) months: Y ^ or No ^
• Are you a registered voter in Miami Beach: Yes ~ or No ^
. (Please circle one): I am now a resident of: North Beach South Beach Middle Bea
• I am applying for an appointment because I have special abilities, knowledge and experience. ease list below:
• Are you presently a registered lobbyist with the City of Miami Beach? Yes ^ or Noy
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 City Clerk's Office. (Regular Boards of City)
D Affordable Housin Adviso Committee ^Housin Authorit
^ Art in Public Places Committee ^ Loan Review Committee
^ Beautification Committee ^ Marine Authorit
^ 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 Quali Education in MB ^ Parks and Recreation Facilities Board
^ Communit 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 Safet Adviso Committee
^ Disabilit Access Committee Safe Committee
^ Fine Arts Board in le Famil Residential Review Panel
^ Ga ,Lesbian, Bisexual and Trans ender GLBT ^ Sustainabilit Committee
0 Golf Adviso Committee ^ Trans arenc Reliabilit & Accountabilit Committee "TRAC"
^ Health Adviso Committee ^ Trans ortation and Parkin Committee
^ Health Facilities Authorit Board ^ Visitor and Convention Authorit
^ His anic Affairs Committee ^ 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 Yes^ No ^. If yes, please list the names of your children, their
ages, and which programs. List below:
Child's name: Age: Program:
Child's name: Age: Program:
gg,~~~ Fax
~S ~i~'F~os~n:
Street
F:`\~ Lodi ,~ii_',~E~,. ,. ~I~% L_C?`~~f~~,li! ~ ~~:~~. ~=~~~;_~ca; c~ni:~u"Lb~~~ NtV'~~ .c~c~c
,,"A`~ ,f"""~,
.Have you ever been convicted of a relony: Yes ^ or No~lf yes, please explain ~~, detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes ^ or No~. If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes ^ or No~ If yes, explain in detail
• Are you cur~entl~ servin~n any City Boards or Committees: Yes or IVo ^. If yes; which board?
• What o~a~-izations ~ the City ofi Beach do you currently hold membership in?
Name:
Title:
Title:
• List all properties 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 N~ Which department?
• Pursuant to City Code Section 2-25 (b): Do you have a parent ^, spouse ^, child ^, brother ^, or sister ^ who is employed by the
City of Miami Beach? Check all that apply. Identify the department(s):
The following information is voluntary and is neither part of your application nor has any bearing on your consideration for appointment. It is
being asked to comply with federal equal opportunity reporting requirements.
Gender: Male ^ Female
E hnic ®rigin: Check one only (1)
White (Not of Hispanic Origin): All persons having origins in any of the original peoples of Europe, North Africa or the Middle East.
^ African-American/Black (Not of Hispanic Origin): All persons having origins in any of the Black racial groups of Africa.
^ Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South American, 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 Native: All persons having origins in any of the original peoples of North America, and who maintain
Cultural identification through tribal affiliation or community recognition.
Yes ^ or No^.
Employment Status:
Retired 0 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 indirectly 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.
re
and truthfulness of the application and have received, read and will abide by Chapter 2,
r~dards f Con uct for City Officers, Em ogees and cy Members."
Date
Please attach a copy of your resume to this application
NOTE: Applications will
r~~
Name of Applicant (PLEASE PRINT)
on file for a period of one (1) calendar year.
Received in the City Clerk's Office by : '~'~`''~G~-
Name of D puts Clerk
Control
Dat : / /2009
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t A M FDADE
S®UCE ®~ IIVC®ME T/~T' E T'
Please Print or Typ
Name:
Mailing Address:
City/State/Zip:
e First Name Noddle Name Initial fast Name
a h ~-fr~ ~ ~--
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Social Security Number:
®isclosure
O=or Tax Year
Ending: ~
O=iling as a: ® County Employee:
® Municipal Employee of: ~ 1~'
Position held or sought: ~ ~ ~ j G ,~~~ j`~-~ y i SC:~ !lJ
Board where serving: ~ ~ ~~ ~ ~-~ Term or Employmen
. Qegan on: ~ G ~
®epartment where employed: N~ ~
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Work Address. ~ ~ C~GG ~~-
If your home address is exempt fmm public records pursuant to `~7~~_ ~ ~ 1 1 _ ~~~~
Florida Statutes § 119.07 please check here (read instructions): ® Work Telephone. - `1 --
Home Address: ~ ~ ~ l.~.C~` e~ `~' ~1 ~ 1 r -~-~`~ ; ~ (.~ Y ~~'7 .1~5 ~~ r~l
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 benefet 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: ® ,
Name of Soturce of Income
Address. ®escription ®f the Principal
Business ~lctivi
~s~ e a ~ ~S ~ - ' ~~ ~ a ~~
I hereb { at the aforesaid information is a true and correct statement.
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Signature tsc using ate signed