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Sidney Goldin 06/10/2014m MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.aov i OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk Tel: (305) 673-7411, Fax: (3051673-7254 i i i 6/18/2010 Sidney Goldin 5415 Collins Ave. Apt.PHA Miami Beach, Florida 33140 - IS ~ABJ.EC~~,~;`~ Health Facilities Authority Board Congratulations! You have been reappointed by the .City Commission to the above I referenced agency, board or committee for a term ending: 6110/2014. If you are unable to accept this appointment, please notify the City Clerk's Office at (305) 673-7411. i Please read the enclosed material carefully. Again, congratulations and good luck. Sincerely, ~~ ~~~ ~~ Robert Parcher City Clerk cc: Saul Frances, Parking .Director Patricia Walker 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 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. m MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.aov OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk Tel: (305j 673-7411, Fax: (305) 673-7254 TO Sidney Goldin RE: .Health Facilities Authority Board 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: 6/10/2014. 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/o~ida Commission on Ethics Guide to the Sunshine Amendment and Code of Ethics for Public t~cers and Employees, and understand that as a member of a City of Miami Beach Board and/or Committee, 1 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. S' ney Goldin Sworn to and subscribed before me thi 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. ® MIAiMf ~~C~l ~ • CETY OF" Mf~M€ BENC~E BE7~P,E~ e41V(e7/COMiVIITTEE ~4PPLICATI01l~ FORi~ NAME: ©L-®~ 5~~~~1` L Name. ., _. r first Name Middle Initial HOME ADDRESS: m ~ ~ ~~ ~~~~ A t `House o./Street City State Zip Code PHONE: t~C~ ~ r~C~ /fib ~~:~o Home Work Fax Email address Business Name: ~'~ 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, 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/interesY.for a minimuin,of'six months in_ a business established in the city. • Resident of Miami Beach for a minimum of six (6) months: Yes`~Qr No ^ • Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes~r No ^ • Are you a registered voter in Miami Beach: Yes ~r No ^ • (Please circle one): I am now a resident of: North Beach South Beach Middle Beach • I am applying for an appointment because I have special abilities, knowledge and experience. ea slow: • Are you presently a registered lobbyist with the City of Miami Beach? Yes ^ or No~ Please list your preferences in order of ranking [1] first choice [2j second choice, and [3j third choice. Please note that only three (31 choices will be observed by the Clty Clerk's Office. (Regular Boards of City) ^ Affordable Housin Adviso Committee ^Housin Authori ^ Art in Public Places Committee ^ Loan Review Committee ^ Beautification Committee ^ Marine Authori ^ 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 D Committee for Quali Education in MB ^ Parks and Recreation Facilities Board ^ Commun' Develo ment Adviso ^ Personnel Board ^ Commun" Relations Board ^ Plannin Board* ^ Convention Center Adviso Board ~ ^ Police,Citizens Relations Committee ^ Debarment Committee ^ Production Indust Council ^ Desi n Review Board* ^ Public Safe Adviso Committee ^ Disabil' Access Committee ^ Safe Committee ^ Fine Arts Board ^ Sin le Famil Residential Review Panel ^ Ga ,Lesbian, Bisexual and Trans ender GLBT ^ Sustainabili Committee ^ Golf Adviso Committee D Health Adviso Committee ^ Trans arenc Reliabili & Accountabil' Committee "TRAC" ^ Trans ortation and Parkin Committee ealth Facilities Authori .Board ^ Visitor and Convention Autho ' ^ is 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 ^,No ^ Years of.Service: ' 2. Present participation in Youth Center activities by your children Yes^ No ^. Ifiyes;`please`list the_ Names of-:your children, ages, and which programs. List below: Child's name: Age: Program: Child's name: their Age:. Program: F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application062609 NEW.doc .Have you ever been convicted of~ony: Yes ~ or No~lf yes, please explaintail: . Do you currently have a violation(s) of City of MiamiJBeach codes: Yes ~~ or No~lf yes, please explain in detail: `` _ . • Do you currently owe the City of Miami Beach~any money: Yes ~ or.No~lf yes, explain in detail ., .Are you currently serving on any City Boards or Committees: Yes C or No~ If yes; which board? • What organizations in the City of Miami Beach do you currently hold membership in? Name: Name: • List all • I am now employed by the City of Miami Beach: Yes-C~or Nod. Which department? • Pursuant to City Code Section 2-25 (b): Do you have a parent ^, spouse`p, 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 compty with federal equal opportunity reporting requirements. Gender: ~' Male ^ Female Title: Title: owned or have~n~terest in, which are located within the City of Miami Beach: CL me vrrgrn: ~neclc one only (~) hits (Not of Hispanic Origin): All persons having origins in any of the original peoples of Europe, North Africa or the Middle East. ^ African-AmericanBiack (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 PaGfic 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 Nod. 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. "I hereby attest to the accuracy and truthfulness of the appli~c~ation and have received, read and wltl abide by Chapter 2, Article VI of a City Code " tan ~.~onduc~// ice/ L c®~Employees and Agency Members., -~•- ----- - -•a••-•-•r ua~e - Name of Applicant (PLEASE PI Pieaseiettachiascopyrof=your~resume`to3tHls~~gpllaatlon NO, ~ :xAppllcatlgnssWllLremain~onsflle'for.a;Perfod~of~one(1):calendar.year. Received in the City Clerk's Office by : Date: _/ /2010 Control No. Date: _/ !2010 Name of Deputy Clerk F:ICLERI$ALL1aFORMS\BOARD AND COMMITTEES\BC Application.doc MIAMHDADE ~ - • 5®191SCE ®F IIVC®ME STATEMENT '~ Please Print or l"ypeFirst Name Middle Name/Initial Last Name Disclosure " ~ For Tax Year Name: S ~ ~ ~ ~ Ending: _. ,~ Mailing Address: ~ ~~L,L~~ ~V~' Ci State Zi : •.. ~// / p ~J Social Security Number: c-3 . -.:~ _ Filin as a: • ' ~ - g ~ County Employee. .___. 3 ® Municipal Employee of: w~ '~ ` ~ ~~ Posifion .held or sought: ~ ~,~ ~1~~ ~ ~ ~~l ~°~~~ sa . ~ ~ " ~6oard where servir ig: O ~ Term or Employment Segan on: -~ ., ®epartmen~ where employed: ~~ V!/ork Address: ' If your home address is exempt from public records pursuant to .Florida Statutes § 1~.9.®7 please check here (read instructions): ® W®rk ~eleph®ne: . ~m~~ Address: Street Address . City State Zip Code Please list below in descending ordea with the largest source first,.ttie 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 dis~losed• ~f continued on a separate sheet, checlk here: ~ ~ ` . ~ ®escrip~i®n o~.~he Principal Narv~e ®f Source of Income business Actiwi . ,., l5~ t ?~, .- { Y hereby swear (or affirm) that the of®s•esaid inf®rmation is atrue aa~d correct statement. ~ - ig, at~re ®f p rs n disc)®sing ®a sig ed .