Karen Brown 12/31/2011m N1IAMIBEACN
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, vrww.miamibeachfl.gov
OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk
Tel: (305) 673-741 1, Fax: (305) 673-7254
03-30-2010
Karen Brown
S;U~BJECT; Gay, Lesbian, Bisexual and Transgender (GLBT)
Congratulations! You have been appointed by Mayor Matti Herrera Bower
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
Rebecca Wakefield
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 to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community.
r
m MIAMII~~,4~~
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.aov
OFFICE OF THE CITY CLERK, Robert Parcher, Ciy Clerk
Tel: (305) 673-741 1, Fax: (305) 673-7254
TO Karen Brown
RE: Gay, Lesbian, Bisexual and Transgender
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 Code of Ethics for Public Officers and Emp/ogees, 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.
Karen BTOVdn
.~
Sworn to and subscribed before me this 7 day of ~ KL , 2010.
frjQ-Si via 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 ovr vibrant, tropical, historic community.
€ 3
r`°' NAME:
Last Name
I'~~
~ ~~firs//t~~/N~a~me
" Mid~d a Initial
HOME ADDRESS: ~ 1 O O LNGOt.I~ I~•E/~Z ,~t<
tiyv~ ~eZC.~.. TC... 3.~~,~
Apt No. House No./Street City State Zip Code
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PHONE: ~~ J 3 ~ ~ ~ }o ~~S .t3 ~ / r-OD ?~~o ~f ~f ~~~ F-21PM~7/~C~'YI~i ~Gr_f
Home Work Fax Email address ~ sp~¢. C~
Business Name:
Position:
Address:
No. Street City State Zip Code
Professional License (describe) Expires: ~dtt~~h ~ cnpy of the ##cr~nse
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 ^
e Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: YesSP:br No ^
• Are you a registered voter in Miami Beach: Yes~cOr No ^
• (Please circle one): I am now a resident of: North Beach South Beach Middle Beach
• I am applying for an appointment ecause I have special abilities, knowledge and experience. Please list below:
/-1 l ~i
Are you presently a regis eyed lobbyist with the City of Miami Beach? Yes ^ 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 (3)
choices will be observed by the City Clerk's Office. (Regular Boards of City)
^ 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
^ :Budget Advisor 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
^ Communit Develo ment Adviso ^ Personnel Board
^ Communit Relations Board ^ Plannin Board`
^ Convention Center Advisor Board ^ Police Citizens Relations Committee
^ Debarment Committee ^ Production Indust Council
^ Desi n Review Board' ^ Public Safet Adviso Committee
^ Disabilit Access Committee ^ Safet Committee
^ Fine Arts Board ^ Sin le Famil Residential Review Panel
Ga ,Lesbian, Bisexual and Trans ender GLBT ^ Sustainabilit Committee
^ 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 Advisor 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:
. ~s8[T r &.dp ~~~ TAI.~Y~
Age: Program:
'ti::1..E`,$t~ll.ic'~~fr`P~`iti,fi7;,k~ ANIa C~i:,:Vth°,ITi:-4:S~,CiC Acz~:li::~rlianb:~C}9 P~3::°,+1t.:foc
.Have you ever been convicted of a felony: Yes ^ or No ~ If yes, please explain in 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~EQ If yes, explain in detail
. Are you currently serving on any City Boards or Committees: Yes ^ or No~l. If yes; which board?
• What organizations in the City of Miami Beach do you currently hold membership in?
Name:
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 Nd~ 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 ~emale
Ethnic Origin:, 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.
Physically Challenged: Yes ~ or N _.
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 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.
"t hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
Article VII -oft City Code "Standards of Conduct for City Officers, Employees and Agency Members."
~ ~ ~ -- (o K~tlc.~~ ~ 42ow~
Applica is Signat Date Name of Applicant (PLEASE PRINT)
Please attach a copy of your resume to this application
NOTE: Applications will remain on file for a period of one (1) calendar years
~ t
Received in the City Clerk's Office by : ` ~ Date: _/ / /2010 Control No. ,Date: / /2010
Name of Deputy Clerk F:\CLER\$ALL\aFORMS\BOARD AND C M TTEES\B A lication.doc
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' MM I~ DADE c
OURCE OF INCOME STATEMENT
Please Print or Type First.Name Middle Name/Initial. Last Name
Disclosure
./~ ~ ~~ 1 - 1 ^
. ~ IvG1- ~~~-1~' •v r..~ /~ For Tax Year
..Name: Ending:
°° Mailing.Address; Q L-.~l`~GOL-/J ~ ~ ~Q °
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,City/State/Zip: IM t /~-f-!t 1 ,~j('s1~f',~-~- ~(„ 3 ~ 3
Social Security Number: ~ ~ ~O ~- ~ S . ~ ~~"'~ ~ ,
Filing as a: ® County-Employee: '
,. ® Municipal. Employee of:
..Position held or sought:
," Board where serving: ~,~ .r- (,t; ~ Term or Employment
LUSteSS ~l~Anct,~,° Began on:
..Department where employed:. ~Ng ~~ S u ~'t Q t/r'L ~~~9c'-~-
-Work Address: ~ ~ ~~ ~•.)~~"1 /~-~-"~l`J ~'~/C.~ /, i ~~ ~2 ~~~3f .
If your Home address is exempt from public records pursuant to - 3 o S'.S'3`(.g~jd~
~. Florida Statutes § 119.07 please check here (read instructions); ~ Work Telephone:
Y
Home Address: 1~r ~ p ~.(NGO t.../y (<-0/-~ '~ 3h
°.Street Address
City State _ Zip Code
e 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:
- -- - ''Description of the Principal
Name of Source of Income Address '.Business Activi
- ~ ( ~ '
I hereb s „ear (or afF hat the aforesaid information is a true and correct statement. -
_ Q
• • Signatu a of perso osing D t signe