Jaqueline Hertz 12/31/2011. ~ Congratulations! You have been reappointed by the City Commission to the above .
referenced agency, board or committee for a term endin
. .: 9 ~ .12/31/2011.
. ~.
If~you are unable to~ accept this. appointment, please notify the City Clerk's .Office. at
. (305) 673=7411.
Please read the enclosed material carefully. Again, congratulations and good luck..
.
.Sincerely,
:Robert Parches .
._ ,.
City Clerk ~ ~ -
cc,: Saul Frances, Parking .Director. ~ _
Grisette Roque .
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, 2-2458,. 2-459
` .Ordinance 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 1Nide Permit Application:- (Parking Department Form) =
Booklet -Guide to the Sunshine Amendment. and Code of Ethics`for Public Officers and
.~ Employees ..
• •
m MIAMIC ~~a~~~
City oiF 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 Jaqueline Hertz
RE: Visitor and Convention Authority
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 OfFcers 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.
\_
Jaqueline Hertz
,ir
Sworn to and subscribed before me this ~ day of ~~~ , 2010.
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.
t"~,
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g''~F~r~ ~ ~ y~a~y. ~ ~ 'f ~;' ~ ~~ '~. ~a;~ ~ , . . ` CITY OF MIAMI BEACH.
~_
.~ :BOARD AIV® C06VIMITTEE APPLICATION FORM
- ~ a
. NgME; . f~! rC~ ~ Z. T/~C°..Qt~~~-! ~C.1 ~ ,~ s
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Last Name ~ ~ ~ First Name ~: Middle Initial
_,. .. . .
RESS: SAS I~yrQ;1+ ~t-}o,~. ~~2,~J£~ . ~ hrt:.c ~~~ ~ 33 i~
HOME ADD
'N~ ~ Apt No. '. House No'=/Street • City State. Zip Code
:.
~PHONe C3t~s~ ~~8-'ES'6 L. (~~ ~ ~6 P- t e-tb `1s h~e:C4~' Io c.l lSc~sf'h., n~`~
Home ~ Work Fax Email address
:. ,Business Narne: ~ Position:
Address: . ~ ,
- _ ~ ~ - ~ .~
,; _ 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, ~baards, and committees shall be affiliated v+rith the -city; this
requirement shall be fulfilled in 'the .following ways` a) an individual shall have been a resident of the city fora minimum of six
months; or b} an individual'shall demonstrate .ownership/interest fora `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 ownershiplinterest in abusiness in~Miami Beach fora minimum of six-(6) months: Yes~or No u
• Are you a registered voter in Miami Beach: Yes ~o ~ `
•:•~
o (Please circle one): I am, now a residenf of: ~ North Beach ~ Soup 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;lobbyistwith the City of'Miami Beach?-.Yes .J 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 OTfice. {Regular Boards of City) ~ -~ °"
~ .Affordable Housing-Advisory. Committee ` . ^ Housing Authority '
_ ^ Art in Public Places.Committee ~ ^ Loan Review Committee
^ Beautification Committee ~ ^ Marine Authority
^ .Board of Ad•ustment* ^ 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 Government Nei h. Im rovement
. _.
^"Committee for.Quality Education in MB
O:Parkland Recreation Facilities Board
'^ Communit Develo ,ment Advisa • ^ Personnel $oard
^ Community Relafions Board ~' ^ Planning Board* •
^ Convention'Center Advisor Board ~ 17 Police Citizens Relations Committee . '
^ Debarment Committee ' ' .. ^ Production Industr Council _
^ Design 'Review Board* ° , ~ • ^ Public Safet Advisory. Committee
^ Disabili Access Committee ^ Safet Committee
^ Fine Arts Board - • .'--~ ^ Single Family Residential Review. Panel
^ Gay, Lesbian, Bisexual and Transgender G,LBT} `'~ ^.Sustainability Committee -
^Golf Advisor ;.Committee ~ . , ~ ^ Trans arenc 'Reliabilit 8 Accountabilit Committee "TRAC"
-
_,
Health Advisory.Committee ~ .. ^ Transportation and Parkin Committee
^ Health Facilities Authorit Board- ~ ~ Visitor and Convention Authori '
^ His anic Affairs Committee ~ - ~ Waterfront Protection Committee .
^ Historic Preservation Board _ ,' ~ ^ Youth Center Advisor Board
*Board• Required to File State Disclosure Form
,. ,
e: If applying for Youth Advisory Board,-,please indicate your affiliation with the Scott Rakow Youth, Center: ~d f ~~, ~ . •
Not /V+
-.1. Pasf service on the Youth Center Advisory Board_;, Yes J No ~ ,Years of Service:
:~2.:Present participation in Youth Center, activities by your c_ hildren Yes No iJ. If yes, ..please lisfithe names of your children; their
ages, and which. programs. List below: -
Child's name: ~ ' ~ ~. -Age.: Program: .
Ghild's name: ~ " . ~ Age: Program:
~ , . .
y~/
I ~ - -
~~ .Have you ever been„convicted of ny: Yes ^ or N~`~. If yes,. please explain i~il
' ~a.Do~you currently have a-violation{s}:of.City of. Miami Beach-codes: Yes u or Nod `If yes, please explain in detail:
,... -
' ~ Do-you currently.owe:the City of Miami Beach-any money: Yes ~ or No'~d if yes, explain in detail .
' " . ~ •. Are you currently serving ion .any. City Boards or Committees:. Yes ~t or No ~. if yes; which board?
,.A ,.~. - -.
. ' '- V f;`5 iTa L /~--'~ ~o ~u ~l ~~i..~ TZ o ~ ~ ~t~ ~.~. Z~y _
®VVhat organizations in the City of Miami Beach do you. currently hold membership in?
,.
Name: .. Title: ~ -
._ Name:. ' : .. ~ ~ Title:. •-
. .
. ~.:': o List all properties owned or have an interest in, which are located within the City of Miami Beach: ,
,. ,
' ''~nl am~now,employed by the City of Miami~Beach:.Yes u or-Nd~. Which department?
' ®Pursuan to City!-Code~Section 2-25 (b~: Do you have a parent U, spouse IJ, child ~, broth'er U, or sister iJ vvho is employed by the
City of Miami Beach:? Check all that apply, Identify the department(s):
The following irifo~mation 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 #ederal equal opportunity reporting requirements.
,Gender: ^ Male ~ Female ,.
Ethnic Origin: ,:.Check one only: (1 } `
Whi e (Not of Hispanic Origin): A4l.,persons having origins in any of the original peoples of Europe,..North Africa or the Middle East.
.. - . .
^Afrlcan-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 triba(affiliation.or community recognition:.
Physically Challenged: Yes U or Nod
Employment Status: Employed ^ Retired ^ '. 'Homemaker. ^ Other ^; =
NOTE: If appointed, you will be requiired to follow certain laws which apply to city boardlcommttee members. `
• • These laws include, but are not limited to,.the following: '
. .. o ;P.rohibtion from directly or indirectly lobbying city personne'I .(Miami Beach City•Code section 2=459).
..
.: ~ o. Prohibition from confracting with the city.(Miami-Dade County Cotle section 2-1,1.1).
- ~ ~ • ' . 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: GMB Community DeVelopr`rientAdvisory_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 ,
` - ~ ' o~ those with .whom you have business or, immediate family ties (CFR 570.611). .
..m ~ ~ Upon reques ,copies of ~ese~la'ws may be obtained from the City Clerk:
`.`I hereby :attest to the accuracy and truthfulness of the application and have received, read :and wilt abide-by Chapter 2,.
` ~ a_Arti le VI1 - of the City Code "Standards of Conduct for-City Officers, Employees and Agency Members.." , ,
~i p" ca Signature Date Name of Applicant (PLEASE PRINT)
~, .. _ ~ •
Flea se attach a r_`opy of yo~~r resume to this application ' '
.: NOTE: Applications ~~,~ill rem on file for a period of one (1) calendar year.
4 _ ~•
. .~., 3
Received in the City Clerk's Office by : Date__/ /2010 Control No. ~~ Date: _/2010 / ~
' ~ Name of Deputy Jerk F:\CLER\$ALLIaFORMS\BOARQ AND COMMITTEESI C Applicati n.doc
'.,:~ .. '
IJ A"M I•DADE
®URCE OF INCOME STATEMENT
Please Print orType
Name:
. ~ Ntailing Address:
_~ ~ City/State/Zip:.-.
Disclosure
For Tax Year
Ending: ~~~~
. .
~' .. .::.,Social Security. Number:
Filing as a ~ County Employee:
®. Munici,pat Employee:.®~: :~
Pams~tion heAcB' or s®ught: ._ .,
. ~ .hoard ~rhere serving: ~ ~ Term or Employment
. :. ~o S t~o~4. it ~~~ J~yi10 ~
Began on: Z f
' Department.where employed:
` Work Address•
' If your home address is exempt frosts publec xecords pursuant to
. = ~ ~ 'Florida Statutes § 119.07 please check here (read instructions): ~ Work Telephone;
Home Address:
Street Address
.. City ~ State Zip Code
. .. ~ Please list below in descenaing order'v~ith the largest source first,-the name, address and
wriwwiwa0 {~. ei.i we~~e~ ~wi~svi~as ~~' evRr~~ ~~uwws a~~ vim.... iwww.MS~ iwwSY s~iws~ w..hlii. i.~L~rwr vwe^
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.