Michael Brosgart 12/31/2011 MIAM1BEACH
City of 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 -7411, Fax: (305) 673 -7254
12/3/2010
Michael Brosgart
20 Island Ave Apt. 716
Miami Beach, Florida 33139
SUBJECT Fine Arts Board
Congratulations! You have been reappointed by Commissioner Jorge Exposito
to the above referenced agency, board or committee for a term ending: 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,
4 t )242- 4)?- t
Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
Gary Farmer
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.
� I
® MAMBEACH
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 Michael L. Brosgart
RE: Fine Arts 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: 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 theFlorida 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 ich I have served.
Mic - L. Brosgart
Sworn to and subscribed before me this \1 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.
• •
• G /MIAMI BEACH CITY iA{tflE BEACH
BOARDS AND CQMMIT EE APPLICATION FORM
NAME: CO S g Q,r 1 I"1 1�1i y L •
Last Name First Name Middle Initial
HOME ADDRESS: 20 t S Ond Pry e f� 1 1 J16 M tam i Beach nL 33139
No. Street 1 City State Zip Code
PHONE: aoa Sao 3(o95 305 354- 4229 305 445 0112 On BROW ART@ MA (L. CoM
Home Work Fax Email address
Business Name: akin f% Y O11 CP_ Position: % 1 ecuor
• Address: 26O0' DGigloS Rol 5i-e. Li to Coral Cables ft... 33139
No. S treet City State Zip Co e
Professional License (describe) Expires: Attach a copy of fltu lice nss:
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 /interest for a 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 ri
• Demonstrate an ownership /interest in a business in Miami Beach for a minimum of six (6) months: Yes H or No p('
• Are you a registered voter in Miami Beach: Yes ;( or No 1:.;
• (Please check one): I am now a resident of: North Beach i-; South Beach iY Middle Beach i i
• l am applying for an appointment because I have special abilities, knowledge, experience. Please list below:
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 Office. (Regular Boards of City)
0 Art in Public Places Committee 0 Housing Authority*
0 Beach Preservation Board 0 Loan Review Committee*
0 Beautification Committee 0 Mayor's Green Ad -Hoc Committee
0 Board of Adjustment* ❑ Marine Authority*
0 Budget Advisory Committee 0 Miami Beach Cultural Arts Council
0 Committee on Homeless 0 Miami Beach Commission on Status of Women
0 Committee for Quality Education in MB 0 Miami Beach Florida Sister Cities
0 Community Development Advisory* 0 Normandy Shores Local Gov't Neigh. Improvement;
0 Community Relations Board 0 Oversight Committee for General Obligation Bond
0 Convention Center Advisory Board ❑ Parks and Recreation Facilities Board
0 Debarment Committee 0 Personnel Board*
0 Design Review Board* 0 Planning Board*
0 Disability Access Committee 0 Police Citizens Relations Committee
Fine Arts Board 0 Production Industry Council
❑ Golf Advisory Committee 0 Public Safety Advisory Committee
0 Health Advisory Committee 0 Safety Committee
0 Health Facilities Authority Board 0 Transportation and Parking Committee
0 Hispanic Affairs Committee 0 Visitor and Convention Authority*
❑ Historic Preservation Board* ❑ Youth Center Advisory Board
* Board Required to File State Disclosure form
1
C:1L7ocu vents and S ettinusx:o nnpc:rt>mU ocrai Scatinys'.ertinorary Internet Files C)LK1C a`,HC: Application Revised July 1?! 200? .doe:
•
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 0 No I:.J Years of Service:
2. Present participation in Youth Center activities by your children Yes!.i No :_. If yes. please list the names of your children, their
ages, and which programs. List below:
Child's name: Age: Program:
Child's name: Age: Program:
•Have you ever been convicted of a felony: Yes 0 or No b If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes i.:i or No X. If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes 11 or No )c. If yes, explain in detail
• Are you currently serving on any City Boards or Committees: Yes C or No X. If yes; which board?
• What organizations in the City of Miami Beach do you currently hold membership in?
Name: Title:
Name: Title:
• List all properties owned or have an interest in, which are located within the City of Miami Beach:
aQ .1S/and five. (Apt ?I(, *Warm Beach 33139
• 1 am now employed by the City of Miami Beach: Yes 0 or Nol(. Which department?
• Pursuant to City Code Section 2 -25 (b): Do you have a parent CI, spouse I: >, child 0, brother 11 or sister 0 who is employed by the
City of Miami Beach? Check all that apply. Identify the department(s):
This section is "not required" but desired: Age: d' years old Gender: Male fis Female 0
Ethnic Origin (Check one)
White I& African - American /Black 0 Hispanic: 0 Asian or Pacific Islander 0 American Indian or Alaskan Native 0
Employment Status: Employed ® Retired 0 Home -maker 0 Other 0
"I hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
Article VII — of the City Code "Standards of Conduct for City Officers, Employees and Agency Members."
213/ 01 a ICI 1 chael rBras C hi
Applicant's ignG ure Dat Name of Applicant (PLEA�E 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 City Clerk's Office by / L^ .2( Date UIP
Name of Deputy Clerk
Document Control Number (Assigned by the City Clerk's Office) e?-7 / 0 Entered By Date r
sea 1/25/ 07 io j
2
C:1Docuirien s and Settingsicoinput i1.ocal S(?ltinys! {(?rnpormy Internet Filesi01.K1'.', t3C Application Revised July 18 2007.doc
I
MIAMIBEACH
City of Miami Beach,
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miamibeachfl.gov
CITY CLERK Office CityClerk @miamibeachfl.gov
Tel: 305.673.7411 , Fax: 305.673.7254
Acknowledgement of fines /suspension for Board Members for failure
to comply with Miami-Dade County. Financial Disclosure Code Provision
Code Section 2- 11.1(i) (2)
Board Member name: c\A 0" - ` 1JYa `r
I understand that no later than July 1, of each year all members of Boards and
Committees of the City of Miami Beach, including those of a purely advisory nature, are
required to comply with Miami -Dade County Disclosure Requirements. This means that the
members of City Advisory Boards, whose sole or primary responsibility is to recommend
legislation or give advice to the City Commission, must file, even though you may have been
recently appointed.
You must file one of the following with the City Clerk of Miami Beach, 1700 Convention
Center Drive, Miami Beach, Florida, by July 1 each year.
1. A "Source of Income Statement" (attached) or
2. A "Financial Statement" (attached( or]
3. A Copy of the person's current Federal Income Tax Return
Failure to file according to the Miami -Dade County Code Chapter 1, General
Provision, Section 1 -5 may subject the person or firm to a fine not to exceed
$500.00 or by imprisonment in the county jail for a period not to exceed sixty
days, or both.
t t
Signature: ate:
L
1
COUNTY SOURCE OF INCOME STATEMENT
OUNTY
Please Print or Type First Name Middle Name /Initial Last Name .
Disclosure
For Tax Year
Name: Nk4 ,\,e -\ Y n S 'di Ending :0 0
C(
Mailing Address: 1 7,47 S S-.wA AL ( A \- 11, tO
(kw\: \ 1
City/State/Zip: N M. , �" � 1 � 3 ■
Social Security Number:
Filing as a: ® County Employee:
® Municipal Employee of: t
Position held or sought:
Board where serving: f ,p Y ��, w �,). , Term or Employment
YY c Began on:
Department where employed:
Work Address:
If your home address is exempt from public records pursuant to
Florida Statutes § 119.07 please check here (read instructions): 0 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 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:
Description of the Principal
Name of Source of Income Address Business Activity
L ,,. \ :--.'F ,.1/1.uKti-2 \ \v \ g N.-J b.... \ \ ,A...„(_ L A - ww 'c-
i
1 hereb swear (or affirm) that the aforesaid information is a true and correct statement. p,
....-j
Sig ture o person disclosing D to sl ned
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