Lawrence Fuller 12/31/2011
m .~IAMBEACH
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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: (3051 673-741 i , Fax: (3051 673-7254
12/10/2009
Lawrence Fuller
925 North Shore Dr
Miami Beach, Florida 33141
Disability Access Committee
Congratulations! You have been reappointed by Commissioner Jerry Libbin
to the above referenced agency, board or committee for a term ending: 1213112011.
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,
~~ ~ s~
Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
John Toledo
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.
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m PJ~IAMIBEACH
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City of Miami Beach, 1700 Convention Center Drive, Miami Beoch, Florida. 33139, voww.miamibeachH.aov
OFFICE OF THE CITY CLERK, Robert Parcher, Ciy Clerk
Tel: (305) 673-7411, Fax: (305) 673-7254
TO Lawrence Fuller
RE: Disability Access Committee
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/o~ida Commission on Ethics Guide to the Sunshine
Amendment and Code of Ethics for Pub/ic 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 w~ I have servec(/~, />~
Lawrence
Sworn to and subscribed beforeme this ~1P day of , 20({b
Fp/L i via 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 commined 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
E APPLICATION FORM
L' ~ sition: /~'T/~
No. Street / City State Zip Code
Professional License (describe) /'7" t 1 ~ lyy ~ ~ 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; orb) 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) mont :Yes or No
• Demonstrate an ownership/interest in a business in Mia each for a minimum of six (6) months: Yes or No
• Are you a registered voter in Miami Beac . e e or No
• (Please circle one): I am now a resident o . ~s~i BeacT, 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 _ r No
Please list your preferences in order of ranking (1] first choice [2] second choice, and [3] third choice. Please note that only three 13)
choices will be observed by the Citv Clerk's Office. (Regular Boards of City)
Affordable Housin Adviso Committee ^Housin Authorit
^ Art in Public Places Committee ^ Loan Review Committee
^ Beautification Committee ^ Marine Authorit
^ 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
^ Committee for Qualit Education in MB ^ Parks and Recreation Facilities Board
^ Communit Develo ment Adviso ^ Personnel Board
^ Communit Relations Board ^ Plannin Board`
^ Convention Center Adviso Board ^ Police Citizens Relations Committee
^ Debarment Committee ^ Production Indust Council
^ Desi n Review Board" ^ Public Safet Adviso Committee
Disabilit Access Committee ^ Safet Committee
^ Fine Arts Board ^ Sin le Famil Residential Review Panel
^ Ga ,Lesbian, Bisexual and Trans ender GLBT ^ Sustainabilit Committee
^ Golf Adviso Committee ^ Trans arenc Reliabilit & Accountabilit Committee "TRAC"
0 Health Adviso Committee ^ Trans ortation and Parkin Committee
^ Health Facilities Authorit Board ^ Visitor and Convention Authorit
^ His 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 . If yes, please list the ~~es~) gbtrP children, their
ages, and which programs. List below: ~~~, Q1Q2
Child's name: Age: Program: „~ „ ~~ 6
Child's name: Age: Program:
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application062609 NEW.doc
MIAMIBE~CH ~
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.Have you ever been convicted of a felony: Yes o No ~ If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes o N~ o , If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes r o '. If yes, explain in detail
• Are yokcurrently ~ervj{tg~pn and/ City Boards of.,Committees~s ®or No If yes; which board?
• What orga/niz~at~io~nfs~in the City of Miami Beach do you currently hold membership in?
Name: /\ ,~t/yy ~~./-1/V' Title:
Name: Title:
• List all properties owned or have n interest in, which are located within the City of Miami Beach:
• I am now employed by the City of Miami Beach: Yes op~o~~Vhich department?
• Pursuant to City Code Section 2-25 (b): Do you have a parent . ,spouse ,child ,brother , or sister who is employed by the
City of Miami Beach? Check all that apply. Identify the department(s): ^ ~~ w ,~
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 ^ Female
Ethnic Origin: Check one only (1)
~Whlte (Not of Hispanic Origin): All persons having origins in any of the original peoples of Europe, North Africa or the Middle East.
^ African-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 tribal affiliation or community recognition.
Physically Challenged: Yes - or No_ .
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 application and have received, read and will abide by Chapter 2,
rticle of the City Cod "Standard onduct for City Officers, Employees and Agency Members."
/'Z - 2 3 - 0 9 ~t;~72F/IICg l~} , s~G [~`~'2
icant's Signature Date Name of Applicant (PLEASE PRINT)
Please attach a copy of your resume to this pplication
NOTE: App ations will remain n e f r a period oof,one (1) calendar year.
Received in the City Clerk's Office by : Datel / +"72009 Control No. Date: _/ /2009 o- ~//a
ame of Depu I D ~ ll
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M®~ SOURCE OF INCOME STATEMENT
Please Print or Type First Name Middle Name Initial Last Name ~~~~
`fT;~- -, 6 P~ .
:,,_ /
f~, ~,
, fJl r // f
Disclosure
Name: l.-~A~+~EN~ t~L~2 For Tax Year
Ending
Mailing Address: ~ ~~ ~ -
City/State/Zip:
~6 -~ ~ Ls ~~-o
Social Security Number:
Filing as a: ® County Employee:
® Municipal Employee of:
Position held or sought;
Board where serving: ~ Terrn or Emplo y e t
Began on : J / .y o ~ d
Department where employed:
Work Address: ~~~ ~ d ~
~~
If your home address is exempt from public nuords pursuant to
Rioride statutes § lt9.o7 please cbadc here (read iestructions): ~ Work Telephone:
Home Address:
Street Address
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
received or arty parson received for your benefit or use during the discl public salary you
osure period. The
income of your spouse or any business partner need not be discic:sed. If continued on a
separate sheet, check here: ~
Description of the Principal
Name Sour of Income Ad ress -8usin Aetivi
DO
is a true and correct statement.
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Date signed