Becky Cohen 06/30/2011M I A/V11 ~~
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' City of Miami. Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeaclifl.aov
OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk
~ Tel: (305J 673-7411, Fax: (305) 673-7254
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June 9, 2010
Becky Cohen
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SUB.DECT: COMMITTEE FOR QUALITY~EDUCATION IN MIAMI BEACH
Dear Ms. Cohen:
Congratulations! You have been appointed as a Representative of the PTA for North Beach Elementary
School to the above referenced agency, board or committee for a term ending, 6/30/2011.
If you are unable to accept this appointment, please notify the City Clerk's Office at (305)
673-741 1.
Sincerely,
Robert Parcher
' ~ City Clerk
cc: Saul Frances,'Parking :D'orector
Leslie -Rosenfeld, Liaison
ATTACHMENTS:
Letter of Appointment
Oath
City Code Ordinance section, applicable to agency, board or committee
i 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 2-1 1 .l -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 .Employees
We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community.
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33}39, www.miamibeachfLgov
i OFFICE OF THE CITY. CLERK, Robert P6rcher, Ciry Clerk - , ,
I Tel: (305) 673-74.1 T, fax: (305) 673-7254 '
TO Becky Cohen
RE: Committee For Quality Education in Miami Beach
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 fora term ending: 6/30/2011.
1 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/o~ida 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.
`Rebc Beefy Cohen
Sworn to and subscribed before me this l ~' day of ~u~C , 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.
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. ~ I V 1 ~ ~1 V 1 ~ ~.i~~.1~ ~ V ~ ~ • CITY.OF f~ild~[iiii BEACH. .
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. • •~ BOARD ®COi~iiNill'1'EE ,4i~PLICA-YIO~ FORiiii -
NAME: ~. ~G~ en- °~'"~ ('ibc~~~ ~. • . .
.. ". ~ ;:. Last Name ~ First Name ~. Middle Initial ,
. ~ ' ~ HOMEADDRES$: •~C) C.J ~.L 1 11r~S- ! ~~ ~ ~.tYQ'"~ ~!'IiGI ~C[-t ' 1-•1 3~ )`'(C~'
E " a • Apt No. - House No./Street °- City State 1 Zip Code
i PHONE:' - C36~~) s~s'-I~ ~~ ~ ° S~P~~~~t~ ~c~en~ 1~~ ~~.1ca•-~~.n~,.}.
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• Home ~. Work ,. Fax Em it address '.
Business Name: + ~ d `D SSG -.vs ~C i' ~/we 5~ 1`'trn-~sition> ~ c~ ~'i-n e : ~ `
~' :. ~ Address: _, ~'~ ~ ~ • 'f= ~f~ l @ c,' ;~,-!-: e~~- ~ 3 G c, _ . • ~•-'~, ~;,t-,, a' ~ ~~. ~ J ~ i ~ ~
No: h. , . Street.. ; ~ City ~ • State Zip Code . • .
` ~~ Professional License (describe) ~ ~ ~ 'Expires: Attach a copy of tfife license -
~ Pursuant to City Code section 2-22(4) a`and b: Membets of agencies; boards, and committees shall be affiliated with the-city; this
requirement shall ,be fulfilled in the following wayss a) an individual shall-have-.been a resident of the city, fora minimum of six
months;., o.r b) an individual shall demonstrate ownership/interest for a minimum of six months in a business established in the city.
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• Resident of Miami°Beach for aininimum of six.(6) ;months: Yes~~or No ^ ~ „"
~. .Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months, Yes ~ or No
f •'Are you~a .registered voter in Miami Beach: Yes~'i'or No' ^ ` ~ •
~: ,. (Rlease circle one): tam now a resident of: _ . North_ Beach South 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. lobbyist with the City of Miami Beach? Yes ~ or No ~ ,
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Please list your preferences in order of ranking.[1] first choice [2] second. choice, and [3] third choice: Please note that only three f3) -
choices will be observed by the Citv Clerk's Office. (RegularBoards of City) ~, ,
^ Affordable Housin `'Adviso Committee ; _ ~ Q Housin Authori '~
I ^ Art in Public Places Committee - " ~ ^ Loan Review Committee -
{ ^ Beautification Committee _ ^'Marine Authorit ~ `
I ^,.Board of Ad'ustrrient" ^ Miami Beach Commission for Women
{ ~ Bud et Adviso Committee ~ , . ~ Miami. Beach Cultural Arts Council ..
k ^ Ca ital Im rovements.Rro~ects Ovecsi ht Committee ^ Miami Beach Sister Cities Pro ram
{ 0•.Committee on the Homeless ^ Normand Shores Locaf Government Nei h. Im rovement
Committee forQuali Education in MB' `~ > ~ ^ Parks and Recreation'Facilities Board ~ `
f ^Communi Develo menf Adviso "p Personnel Board - `' - ,
^Communi Relations Board ^ Plannin Board" `
1 ^ Convention Center.Adviso Board ~^ Police`Citizens Relations Committee •
Debarment Committee ~ -> ~ - ~ Production Indust •Council
{ ^ besi n Review Board', ~', ~ - ,:^ Public Safe Adviso Committee
^ Disabili 'Access Committee ~ ' ~ . ~ ^ Safe Committee -
~ ~ fine Arts- Board ~ ~ ^ Sin le Tamil Residential Review Panet
i o Ga ,Lesbian, Bisexual and Trans i3nder GLBT ^ Sustainabili Committee
j ~ Golf Adviso Committee ~ . •~ ~.
^.Trans arenc Reliabili & Accountabili Committee "TRAC"
{ ^ Health Adviso Committee.. ~ ^ Trans ortation and.Parkin Committee
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^ Health Facilities Authors Board . ° ..
^ Visitorand Convention Authori `
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~.^ His anic Affairs Committee ^ Waterfront'Protection Committee
{ D Historic Preservation Board .
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^ Youth Center Adviso Board
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[ • ~ ~ • 'Board Required to Eile State Disclosure Form .
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Note: If a I m fior Youth Adviso Board, lease indicate our affiliation with the Scott Rakow Youth Center: `
• l Pp Y~ g rY P y
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~1. -Past service, on the Youth Center Advisory Board:. Yes ^ No ^ Years of Service: ,
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ageseandtwhich otroa~s:Youth Center activities'by your children Yes^ No ^. If yes,. please fist the names.of your children, their
p g List below:
n ~ ~Chdd's name: Age 'Program:.
` tChild's name: ~ . ~ i Age: Program: _
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.. ~ 1F:\CIER\$AI:L\aFORMS\BOARD AND GO/vIMITTEES\BC Application062609 NEW.doc ~. •
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..Have you .ever been convicted of a felony: Yes ~ or No, If yes, please explain in detail: ~ i
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.~Do yota currently have a violation(s) of City of Miami Beach codes:'Yes ~ or Nolf yes, please explain in detail:
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• Do you currently owe the City of Miami Beach any money: Yes o or No If yes,, explain in detail `
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' : j • OAre you currently serving.on any City Boards or.Committees: Yes ~ or No If yes; which boards .
• ~ • What:organizations in tha.City of Miami Beach do you currently hold membership in?
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Name: • .` Title:
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~ .Name:.. • ~ .. - Title:. -
• List all• properties owried or have an iritere§t in, which ar'e located within the City of Miami Beach:
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• 1 am now employed by the City.of Miami Beach.: Yes ^ or No~ Which department?
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' ', # • Pursuant to•City Code Section 2-25-(b): Do you have a parent. o, spouse ~, child:g brother ^; or sister ^ who is employed by the ~ . .
"City of Miami Beach? Check alhthat apply` Identify the department(s):.. ~ ~ • ~ '
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The•following information is voluntaryand is neither part of your application nor has any bearing on yourconsideration for appointment:'it is
i being asked to comply with fiederal equal opportunity reporting requirements.
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.. ; Gender: ~ Male Female
~ Employment Status: Employed ~~ "Retired ^ .Homemaker ^ ~ Other D'•. , ' ~ • '
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} ~_ 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:
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'~ G ", :~. o -Prohibition from directly or indirectly lobbying city personnel (Miami Beach City Gode'section 2-459). '
• ' ~ 'o~ " Prohibition from contracting with the city (Miami-Dade County Code section 2-11x1).. ~ ' , '
- ( . , o Prohibition from lobbying before board/committee you haveserved ~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 section2-11"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 (GFR 570611). ~ -
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~. { Upon request, copies of these laws may tie obtained from the City,Clerk..
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"1 hereby attest~to the accur y and truthfulness of the application and.have received, read and will abide by Chapter 2, .'
; .Article VII"- f e i o e Standards of Conduct for City Officers, Employees and Agency Members."
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Ap~li ~' Signature Date, Name•of Applicant (PLEASE PRINT)
i • PI ~ se attach a co _ of "our _. ~_'~..~~~.~~__.~.~~. •,
. ~_._ _ pY.,_ Y resume to this application __._ _ _ _~~ - ~~~_ ~ I
' ~ j • ~ ' ` NOTE: Applications will rem m on file fora .period of one (1) calendar years
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Received in the Ci Clerk's Office b y ~ Date: _/ /2010 Control N~ Date: D/ /20 O S
Ty Y
` 'Name of Deputy Clerk F:\CLER\$ALL\aFORMSIBOARD AND OMMITTEES\BC A plication.doc
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I A M hDADE
~ SOURCE OF INCOME STATEMENT
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Please Print or Type
Name:
Mailing Address:
City/State/Zip:
rust name rnaa~e name tmna~ ~.ast name
~e~~. ~ ~ ~~ ~ e ~ ,
s~ov C~.~~1ir~i ~c ~f~o`I
Disclosure
For Tax Year .
Ending:
Social Security Number: ~~ ~~ ~~ (3 ~ ~
Filing as a: ® County Employee:
® Municipal Employee of:
'Position held: or sought:
Board where serving: Term or Employment
' Began on:
Department where employed: -
Work Address: _ '
Ifyour home address is exempt from public records pursuant to
Florida Statutes § 119.07 please check here (read instructions): ® Work Telephone:
Home Address: ~~!)6 ~~~`\rS ~~~ '~ (~~`~
Street Address .
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. • .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 Descciptlonof the Principal..
'Business Activi
S1D'f~'~G/~ Slav i ~G^FCn ~t.wc - 1 ~ICt.~I-.
af~s`~1c C.cc a'S G. C~ Gc - n - 3 ~r~-ner- jb,~~~~q.
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~~' r ~ <e.l- C°L cf}'C `,.. ~ { r f SC'~"nC.t' ® rju~ cl~
I hereby swear (or affirm) it>tat the aforesaid information is a true and correct statement.
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Sign of p n disclosing Date signed
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