Michael Burnstine 12/31/2011. _ ~ .
\~ (~~ ..
- ~ City of Miami .Beach, 1700 Convention Center Drive,-Miami Beach; Florida'33139, www.miamibeachfl.Qov
... ~ 4
' OFFICE OF THE CITY CLERK, Robert Parches, Ciry Clerk ..
Tel:, (3 051 673-7411 1, Fax: (3051673-7254
3/26/2010
:Michael Burnstine ~ `
4447- N. Bay Road 1 . -
Miami Beach, Florida 33140 ~ `
SUBJECT: Affordable Holusing Advisory Committee .. .
. Congratulations!; You shave been ;reappointed by-the City Commission to the above .'
referenced agency, board or committee for a term ending: 1213112011.
If you are unable to accept this appointment, please notify the City Clerk's Office at ~ "
. (305) 673-7411.
-. Please read he enclosed material carefully. Again, corigtatulations and good luck:.
Sincerely, ~ ..
- `Robert -Parches
.City Clerk. .. _ :. .
cc: Saute Frances, Parking Direclror -
Anna Parekh .
~, ATTACHMENTS: .
Letter of Appointment ~ F
` Oath • .. ~ -
• --City Code Ordinance section, applicable to agency, board orcornmittee
City Code. Section,2-22, 2-23,.2-24,.2-25, 2-26, 2-2458, 2-459 i
- Ordinance 2006-3543 -Amendment to City Code Section.2-22
Miami-Dade,Couhty~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_Annendment and Code of Ethics for Public Officers and
Employees ,
We ace committed to providing eiccellent public service and safety to all who live; work and play in our vibrant, Tropical, historic community.
m MIAMI~~~,CW
City of Miami Beach, 1700 Convention Center Drive,' IvliamitBeach:Floricla:33:1.39; www.miamibeaclifl:gov ~=',~:•.', '.' `'_'._: 'wj ..<
OFFICE OF THE CITY CLERK, Robert Parcher, Ciry Clerk "'• '-"" "•-'' ' "'' :` :: ` - '" ~"
Tel: (305)'673-741 1, Fax: (305) 673-7254 °<~ ~~ ~ . ~~., ..• . ;~ .: '- - .." .
TO Michael Burnstine
RE: Affordable Housing Advisory 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 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 year on which I have served.
Michael Burnstine
Sworn to and subscribed before me this ~ day of ~ ~/ L , 200,w
~~~
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 MIAMI~~P,~I~
NAME: ~vmb~
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/Bt?A~® r~R9® C®6~fr~fJBT~'E~ ~PPLBC~~I®f~ ~®R6~i
Last Name ,, I First Name ~ Middle Initial
HOME ADDRESS: ~ ~~ ~ I Y - ~~I RCX~C~ ~PCc~1)~' i~C~~ F'L 33 ~ ~Q
Apt No. House o./Street City State Zip Code
PHONE:_3~5-53~- s~i,s gs~-X83-alao Ni%~~,cc/a~6~~i,sfi~e.~
Home Work Fax Email address
Business Name: L-oC~`~ COrnO~;~S Position: Ur~° t"~2r~C~2~~
Address: _ 3~~~ S ~ l(PD ~ S~'fe a W M~~~~~ i2 ~ 33oa~-
No. Street City State Zip Code
Professional License (describe)
Expires: Attach a copy of the license
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/interes or a minimum of six months in a business established in the city.
• Resident of Miami Beach for a minimum of six (6) months: ~ or No
• Demonstrate an ownership/interest in a busirlp.~ss in Miami Beach for a minimum of six (6) months: Yes o No
• Are you a registered voter in Miami Beach: ~ or No
• (Please circle one): I am now a resident of: North Beach South Beach Middle Beach
• I am applying for an appointment becaus I have speci I abilities, know edge a d experience. a se ist below:
-~'Mer C[~~`rMU.~ o~ WD~fc~2L ~^nc, ~~nm•{~ Q7 ~/(/1PGM: ~w.~a~~iltPlCc
• Are you. presently a registered lobbyist with the City of Miami each? Yes or o
Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that only three 131
choices will be observed by the Citv Clerk's Office. (Regular Boards of City)
Affordable Housin Adviso Committee 1 Housin Authori .
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 Qualit Education in MB Parks and Recreation Facilities Board
Communi Develo merit Adviso Personnel Board
Communi 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 Sin le Famil Residential Review Panel
Ga ,Lesbian, Bisexual and Trans ender GLBT Sustainabilit Committee
Golf Adviso Committee Trans arenc Reliabilit & Accountabili 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 V~ Years of Service:
2. Present participation in Youth Center activities by your children es No . If yes, please list the names of your children, their
ages, and which pr rams.,~ist below:
Child's name: ~nsfi~ Age: ~ Program: ~s~ze~{b~l/
Child's name: Age: Program:
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application062609 NEW.doc
oHave you ever been convicted of a felony: Yes o~'NO~j If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes C~ . If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes o~~ . If yes, explain in detail
• Are you currently serving on any City Boards or Committees: Yes `~~ If yes; which board?
• What organizations in the City of Miami Beach do you currently hold membership in?
Name: Title:
Name: Title:
. List all properties owned or have an interest in, which are located within the City of Miami Beach:
~~y~ N~ ~~, ~c
• 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:
Female
Eti~tic 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-AmericaNBlack (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.
sically Challenged: Yes
Employment Status:
Retired Homemaker Other
NOTE: If appointed, you will be required to follow certain laws which apply to city boardlcommittee 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.
"f hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
Article - f t~~~ity_Code "Standards of Conduct for City Officers, Employees and Agency Members."
Applicant's Signature at Name of Applicant (PLEASE PRINT)
Please atta_ch__ a. copy of your_resume to this application _ _ _ _ _
^NOTE: Applications will remain~n fle for a,period of one (1) calendar,year ~-7
Received in the City Clerk's Office by : ~ - Date: _/ /2010 Control No. 'r ~ Date:
Name of Deputy Clerk F:\CLER\$ALL1aFORMS\BOARD AN C~EES\B
1 A M hDADE
_~ SOU'RCE OF INCOME STATEMENT
Please Print or Typ
Name:
Mailing Address:
City/State/Zip:
e First Name Middle Name Initial Last Name
/'~ i ch ~-e-I Lei ~ vrnsf - ne
l~i'~.r~n ~ ~ ~ ~L 331 ~{ o
Disclosure
For Tax Year
Ending:' 31 ~
Social Security Number: ~ ~ (' ~ ~~ - ~~ S3
Filing as a: ® County Employee:
® Municipal Employee of:
Position held or sought: ~j(,; y~b~r o{ /~{~~C ~,.,m;
Board where serving: ~ ~~~ ~Mm ~ .~C Term or Employment
Began on:
Department where employed:
Work Address: ;360 si,~ l~Oo ~{ /U~,Y~ ~ ,33oa"~
If your home address is exempt fn-m public records pursuant to
Florida Statutes § 119.07 ple/ase check here (read instructions): ® Work Telephone: 3~-g~y-~~~
Home Address: ~~N~ /~ g~ ~~.
Street Address
~~~~ ~~~, ~ ~3~Yd
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:
.. - ; ..
'Name of Source of Income ,. ~ ;:
~ Address ~
De
sc_ripton_of thePrincipaf
'_.Business Activi
~CCIE-M ~m ~~i~5 LAC 3601 5W loo ~ ~L ~~P~'c~w Sns~''~ce oe
e
I hereby swear (or affirm) that the aforesaid information is a true and correct statement.
/~~~ 9 0
Signature of person disclosing a e signed
~~~