Ann Thomas 12/31/2010m MJAMIBEACH
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: (305) 673-741 1, Fax: (305) 673-7254
5/29/2010
Ann Thomas
465 Ocean Dr #516
Miami Beach, Florida 33139
SUBJECT: t Disability Access Committee
Congratulations! You have been reappointed by Commissioner Jorge Exposito
to the above referenced agency,i board or committee for a term ending: 12/3112010.
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, j
Robert Parcher '~
City Clerk
cc: Saul Frances, Parking Director
Duane Knecht
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
i
We are committed to providing excellent public service and safety to aH who live, work and play in our vibrant, tropical, historic community.
MIAMI BAC'
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachH.aov
OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk
Tel: (305) 673-7411, Fax: (305) 673-7254
TO Ann Thomas
RE: Disability Access Committee
I do solemnly swear or affirm to bear true faith,
oyalry 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: 12/31/2010.
I have been issued a copy of Section 2-11.1 ofthe 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 Emp/ogees, and understand that as a member
of a Ciry of Miami Beach Board and/or Committee, I must comply ith the financial disclosure" require-
ments of Miami-Dade County or the State of Florida (depending o the board or committee on which
I serve) on July 1st, following the closing of the, calendar year o hich I have s~c~
~" I Ann Thomas
Sworn to and subscribed before me this day of 2010.
Silvia ne o
~; Deputy Clerk
i
*Please visit the City of Miami Beach website at wiww.miamibeachfl.gov under City Clerk/Board and Committees
for additional information regarding the Financial Disclosure Requirements.
We are committed ro providing excellent public service and safety to all who live, work and play in our vibrant, -ropical, historic community.
•
NAME:
!~JAfs,l BEACH
/~;
C[T1' OF MlAfdll i3~ACH
BOARD AND COMMITTEE APPLICATION FORM
~~~ ,
Las~t/N/ame /~ ^j ~Na~e~6 - Middle Initial
HOME ADDRESS: Y'"(7 S t-l'C~ ~/l/ Q~'e ~ j/~ 'T/_~~ ~L- ~~~3 ~J'
No. ~ Street City ll ~ Zip Code
PHONE: ~ ~~- S3 Z '"" I ~~~ ~ ~~~' ~ ~ •- ~l''Q ~ ~~iv~/JOA~1ff -Si~Y~t~OO ~Fc~
Home
Fax
Email address
'r'!~~
Business Name: ~ Position:
Address:
No. ! Street City State Zip Code
Professional License (describe) ~! Expires: Attach a cop}~ 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; orb) an individual shalt demonstrate ownershiplinterest for a minimum of six months in a business established in the city.
• Resident of Miami Beach for a minimum of six (6) months: Ye or No ^
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes ^ or Nov
• Are you a registered voter in Miami Beach: Yes or No ^
• (Please circle one): I am now a resident of: North Beach outh Beach Middle Beach
• I am applying for an appointment because I have special abilities, knowledge, experience. Please list below:
i
Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that only three (31
choices will be observed by the Citv Clerk's Office. (Regular Boards of Gity)
^ Affordable Housin Adviso Committee ! ^ Historic Preservation Board*
D Art in Public Places Committee D Housin Authori *
D Beach Preservation Board ! ^ Loan Review Committee`
D Beautification Committee ^ Marine Authori
^Board of Ad'ustment* ; D Miami Beach Commission for Women
D Bud et Adviso Committee Miami Beach Cultural Arts Council
^ Ca ital Im rovements Oversi ht i iami Beach Florida Sister Cities
D Committee on Homeless I ormand Shores Local Gov't Nei h. Im rovement i
^ Committee for Quali Education in MB I ^ Parks and Recreation Facilities Board
^ Communit Develo ment Adviso * ^ Personnel Board*
^ Communit Relations Board ~ D Plannin Board
^ Convention Center Adviso Board I ^ Police Citizens Relations Committee
^ Cultural Arts Nei hborhood District Overla (CANDO ^ Production Indust Council
0 Debarment Committee ; ^ Pubfic Safe Adviso Committee
^ Desi n Review Board* I ^ Safet Committee
isabilit Access Committee I ^ Sin le Famil Residential Review Panel
^ Fine Arts Board ^ Sustainabilit Committee
^ Ga Business Develo ment Ad Hoc ', D Trans arenc Reliabilit ~ Accountabilit Committee "TRAC"
0 Golf Adviso Committee I ^ Trans ortation and Parkin Committee
^ Health Adviso Committee ; D Visitor and Convention Authorit "
^ Health Facilities Authorit Board 'i ^ Youth Center Adviso Board
^ Hispanic Affairs Committee
~ i I *Board Required to File State Disclosure form
~~ :r::~FR1~A'_~1F3oarc i> C;c,m~7nh~es\6&•_. Appiicauocii6ix:: Hunhcauor. Fievi~lsc ?'~ 13Db.duc
"s
I
.Have you ever been convicted of~lony: Yes ~ or No ~ If yes, please explain in etail.
• Do you currently have a violation(s) of City of Miami Beach codes: Yes C or No L! If yes, please explain in detail:
- - - _ ~
• Do you currently owe the City of Miami Beach any money: Yes ~ or No ~ If yes, explain in detail
• Are you currently serving on any City Boiards or Committees: Yes~'or No C. If yes; which board?
• What organizations in the City of Miami Beach do you currently hold membership in?
Name: I Title:
Name: I Title:
i
• 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'IBeach: Yes ^ or NoC~(Which department?
• Pursuant to City Code Section 2-25 (b): Do you have a parent ^,~spouse D, child ^, brother ^, or sister ^ who is employed by the
City of Miami. Beach? Check all that apply. Ideritify the department(s): s'o ~ ~~
~ /V
--
The following information is voluntary and Is
being asked to comply with federal equal opl
Gender: ^ Male ~, Female
Et Ic Origin: Check ne only (1
~ White (Not of Hispanic Origin): All persons
^ African-AmericanBlack (Not of Hispanic
part of your application nor has any bearing on your consfderatlon for appointment. It is
~ reporting requirements.
origins in any of the original peoples of Europe, North Africa or the Middle East.
All persons having origins in any of the Black racial groups of Africa.
^ Hispanic: All persons of Mexican, Puerto Ricari, 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
Guttural identification through tribal affiliation or community recognition.
Yes,~or NOO.
Employment Status: Emplo~/ed ^ 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). ~I
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 st to uracy and truthfulness of the application and have received, read and will abide by Chapter 2,
Article VII of the City C e rds of Gonduct for City Officers, Employees and Agency Members."
cant' S gnature l Date ame of Applicant (PLEASE PRINT)
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
of
Control No. j~~ Date:/ / 00 `/~~
.. ~I6 ~
b I
3
MI® S®~J
Please Print or Type First Name
Name: ~ ~
Mailing Address: `~'~O
City~State/Zip:. 3 ~
Social Security Number:
Filing as a: ® County Em
® Municipal E
Position held or sought
Board where serving:
OF INCOME STATEMENT
Middle Name/Initial _ last Name
Disclosure
.~.._Q For Tax Ye
(7 /~ / ~~ EndingG
J~~
3 9 ~-~
ree:
loyee of:
«h~
.~ j Term or Employment
Began on:
Department where employed:
Work Address: f
If your home address is exempt from public records pursuant to
Florida Statutes § 119.07 please check here (read instructions): ® Work
Home Address: ~;~~a~~~~1~ ~~
Street Address
CI ty State Zip Code
yV
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:
Descriptioro of the Principal
Name of Source of Income _ Address Business Activity
I hereb wear {or affirm ~tthe aforesaid information is a true and correct statement.
r
igna ure of p rso sing Date si ned