Ivan Pol Board and Committee Applicationm MIA^J~IBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www miamibeachfl,gov
OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk
Tel: j305) 673-741 1, Fax: (305) 673-7254
04-22-2010
Ivan Pol
5445 Collins Ave. #1232
Miami Beach, Florida 33140
'SUBJECT: Production Industry Council
Congratulations! You have been appointed by Commissioner Jerry Libbin
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
Graham Winick
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.
m MIAMI~E.~C~i
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk .,
Tel: (305) 673-741 1, Fax: (305) 673-7254 , . , , ,.
TO Ivan Pol
RE: Production Industry Council
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 dis osure* re i
ments of Miami-Dade County or the State of Florida (depending on the boar co icY
I serve) on July 1st, following the closing of the calendar year on whi ave rued.
I Pol
Sworn to and subscribed befor day of _~~ 010.
Silvia Prieto
Deputy Clerk
*Please visit the City of Miami Beach website at www.miamibeacfifl.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.
NAME: POL IVAN
Last Name First Name Middle Initial
HOME ADDRESS: 1232 5445 COLLINS
AVENUE Miami Beach FL 33140
Apt No. House No./Street City State Zip Code
PHONE: 786-546-8215 305-538-8006 IVANP77@AOL.COM
Home Work Fax Email Address
Business Name
ORIBE SALON
Position: MAKE UP ARTIST/STYLIST
33139
Address:
1627 EUCLID AVENUE @ LINCOLN
ROAD
Miami Beach FL
No. Street City State Zip Code
rroressionai ucense ~aescnoe/: txpires: :n a copy or the ucense
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
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes
• Are you a registered voter in Miami Beach: Yes
• (Please circle one): I am now a resident of: Middle Beach
• I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
I'VE BEEN WORKING IN THE TOP OF THE FASHION/PRODUCTION/COMMERCIAL INDUSTRY FOR 10 YEARS. AS A
LEADING CELEBRITY MAKE UP ARTIST AND STYLIST.
• Are you presently a registered lobbyist with the City of Miami Beach? 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)
Art in Public Places Committee Loan Review Committee
Board of Adjustment Miami Beach Commission for Women
Budget Advisory Committee Miami Beach Cultural Arts Council
Capital Improvements Projects Oversight Committee Miami Beach Sister Cities Program
Committee on the Homeless Normand Shores Local Gov't Nei h. Im rovement
Committee for Quality Education in MB Parks and Recreation Facilities Board
Community Development Advisory Personnel Board
Community Relations Board Planning Board*
Convention Center Advisory Board Police Citizens Relations Committee
Debarment Committee [1] Production Industry Council
Design Review Board* Public Safety Advisory Committee
Disability Access Committee Safety Committee
Fine Arts Board Single Family Residential Review Panel
Gay, Lesbian, Bisexual and Transgender (GLBT) Sustainability Committee
Golf Advisory Committee Transparency Reliability & Accountability Committee "TRAC"
Health Advisory Committee Transportation and Parking Committee
Health Facilities Authority Board Visitor and Convention Authority
Hispanic Affairs Committee Waterfront Protection Committee
Historic Preservation Board Youth Center Advisory Board
o e: app yang or ou visory oar ,pease in ica e your a i is i ~: hoar ~2equ°ired ~o ~i~e ~a a isc~osure form
1. Past service on the Youth Center Advisory Board: No Years of Service:
2. Present participation in Youth Center activities by your children 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:
• Have you ever been convicted of a felony: No If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: No If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: No If yes, explain in detail
• Are you currently serving on any City Boards or Committees: No 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:
• I am now employed by the City of Miami Beach: No Which department?
• Pursuant to City Code Section 2-25 (b): Do you have a 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 Race: White
Ethnic Origin: Check one only (1)
Hispanic
Physically Challenged: No
Employment Status: Employed 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.
"I hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
Article VII - of the City Code "Standards of Conduct for City Officers, Employees and Agency Members."
I IVAN POL agreed to the following terms on 3/23/2010 10:31:58 AM
Please attach a copy of your resume to this application
NOTE: Applications will remain on file for a period of one (1) calendar year.
Received in the City Clerk's Office by:
Date: _/ _/ Control No. Date: _/_/
Name of Deputy Clerk
IAMhDADE ~ -
~ SOURCE OFINCOME STATEMENT
~. .
Please Print or Type First Name Middle Name/Initial Last Name
Name: ~~ ~ •' ~~ `'
_ ' 1 /~, ;,
Mailing Address: ~ ~ ~ ~ ~%~ L L ~ N S ' "' ~ ~ 2.~2
- city/state/zip: 1~~`QMl iJeG1Gv1 I ILL- 3~1 y (~
..Social Security Number:
Filing as a: ® County Employee: ~~
. ® Municipal Employee;of:
Position held or sought:
SCI05Ure
~r Tax Year
Iding:
'.Board where servin
g' ~~~DU+G~ptJ ; INDdI ~iQNULerm or Employm t
Began on: ~.~ l S~la
Department where .employed:
'
Work Address:
If your home address is exempt from: public re ~'rds pursuant to _
florida Statutes.§ 119:07 please check here (read instructions): ~ ® Work Telephone:
Home Address:
i
'Street Address
City f" State Zip Code
Please Gist below in..descending order-with the largest source :first, the name, :address and
principal business activity of every source of our income includin.
Y g 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
aeparate sheet, check here: ~ ~
:Name of~~Source..of::Income
;Address. '=Descc t~on:of the.Prmcipal
P
Business:Activi
lb2 .t1~Cli~~ ~ItN ~kL01J - ~~-
Q1C~~' C2- Mia~tll~!-~ i, ~3
(~-~ (~-n~ ~-
(~pSt~~ CS GI~M
' . C4
~~ '
I
~'
I~herebyswear ;affirm) t.the afor a
3' i
+. i
is a true;and correct statement.
~~ ~V
Date si ned
Nay