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Carol Housen 12/31/2012 m► MIAMI BEACH 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 -741 1, Fax: (305) 673 -7254 01 -20 -2011 Carol Housen 7330 Ocean Ter #2001 Miami Beach, Florida 33141 a Design Review Board Congratulations! You have been appointed by the City Commission to the agency, board or committee named above for a term ending: 12/31/2012. Pursuant to Ordinance No. 2006 -3543, commencing with terms beginning on or after January 1st, 2007, the term of board members who are directly appointed by a member of the City Commission shall automatically expire on December 31 of the year the appointing elected official leaves office. If you are unable to accept this appointment or have any questions, please call the City Clerk's Office at 305 - 673 -7411. Please read the enclosed materials carefully. Congratulations again and good luck. Sincerely, /dP}Zifs / r Robert Parcher City Clerk cc: Saul Frances, Parking Director Thomas Mooney 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 -458 and 2 -459 Ordinance No. 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 Employee We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community. MIAMIBEACH 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 TO Carol Housen RE: Design Review 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: 12/31/2012. 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 /orida 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. a /, Carol Housen Sworn to and subscribed before me this /7 day of P " 2011 _A. 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. • M !AM 1 BEACH CITY OF IVIIAMI BEACH A., BOARD AND COMMITTEE APPLICATION FORM *NAME: .0 S 4 Last Name HOME ADDRESS: D0� �33 D `' First Name Middle Initial Apt No. .Q .- , ` , 3 //l H ouse No. /Street City PHONE: i ; State Zip Code Home yy ra .'� 93 et i. Business Name: • �-, - �'Q Fax Email address mama/ /46.� ,' osition: • , / Address: , 40 -- .. 4o o . No. Street t� City State Zip Code Professional License (describe) , , D / - 7 1 Expir 4 Z 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 /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: Yeor No ❑ • Demonstrate an ownership/interest in a business in Miarrg 9each for a minimum of six (6) months: Yes* or No ❑ • Are you a registered voter in Miami Beach: Yes ❑ or No 4 • (Please is role one): I am now a resident of: • I am applying for an ap iiotment because I have s North c aB bil' es no edge n ex• erience. Please list below: ' � e r //loch cou j op Middle Beach • Are you presently a iste _• rie reg lobb ist with C'ty of Mi - , = ch? Yes ❑ or No + G � / ea � 9 /� • Please list your preferences in order of ranking [1] first ch e ice [2] second choice and [3] third choice . Pl S , , that �' aQ,t` c hoices will be o by the Clty Clerk's Oifl (Regular Boards of City) Please note that only three f31 ❑ Affordable Housin• Adviso Committee ❑ Art in Public Places Committee ❑Housin, Authori ❑ Beautification Committee ❑Loan Review Committee ❑ Board of Ad'ustment' ❑Marine Autho • ❑ Bud.et Adviso Committee 0 Miami Beach Commission for Women ❑ Ca • ital Im • rovements Pro'ects Oversi • ht Committee ❑ Miami Beach Cultural Arts Council ❑Miami Beach Sister Cities Pro. ram 0 Committee on the Homeless ❑ Normand Shores Local Govemment Nei • h. Im • rovement ❑ Committee for Qual' Education in MB 0 Parks and Recreation Facilities Board ❑Communi Develo•ment Adviso 0 Communi Relations Board ❑Personnel Board 0 Convention Center Adviso Board ❑ Plannin • Board* ❑Debarment Committee 0 Police Citizens Relations Committee Desi• n Review Board• 0 Production Indust Council ❑ Disabil' Access Committee ❑Public Safe Adviso Committee 0 Fine Arts Board ❑Safe Committee ❑ Ga ,Lesbian, Bisexual and Trans ender GLBT 0 Sin! le Famil Residential Review Panel 0 Golf Adviso Committee ❑ Sustainabili Committee ❑ Trans • ortation and Parkin • Committee c ❑ Health Adviso Committee -‹ o ❑ Health Facilities Authori Board ❑Visitor and Convention Authori ..,e ❑ His.anic Affairs Committee 0 Waterfront Protection Committee • 0 Historic Preservation Board ❑Youth Center Adviso Board *Board Re • uired to File State Disclosure Fdrrm ;1 --z Note: If applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Center: o c-- N) 1. Past service on the Youth Center Advisory Board: Yes ❑ No 0 Years. of Service: 2. Present participation in Youth Center activities by your children Yes❑ Nb 0. 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: __/4 F \�lER \tia \aFORMSIBOARD AND COMM1TTEES\BC ApplicationO62609 NEW. sc an, 1 •Have you ever been convicted of a felony: Yes " or If yes, please explain in detail: _ . J • Do you currently have a violation(s) of City of Miami Beach codes: Yes LI o er. If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money: Yes _ o t,_:. If yes, explain in detail • Are you currently serving on any City Boards or Committees: or No If yes; which board? P ,tJ . i : ' - 0 • What organizations in the City of Miami Beach do you currently hold membership in? yy Name: 4 _ ' v' 0 / I et Title: PX-4 1 u _/ I, . • Title: O hjthe L-/ A o d Nam_ /// . � • List all properties awned or have an interest in, which are located within the City of Miami Beach: /5'6 , 5 - 7( 1 -1 ' -2100 • ' • I am now employed by the City of Miami Beach: Yes 0 0 on ich department? • Pursuant to City Code Section 2 -25 (b): Do you have a parent 0, spouse C, child 0, brother 0, or sister 0 who is employed by the City of Miami Beach? Check all that apply. Identify the department(s): J at The following information is voluntary and is neither part of your application m nor has any bearing on your consideration for appointment. It is being asked to comply with federal equal opportunity reporting requirements. Gender: ❑ Male ,iTFemale -Ethnic Origin: Check one only (1) White (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 0 or Nq. Employment Status: Employe. r; Retired ❑ Homemaker ❑ Other ❑ NOTE: If a noii' de,, you will not required d follow certain laws which apply to city boardlcommittee members. These la 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). prohibition, during tenure and for one year (re: having Y y int rest i any benefit from Community Development Block Grant funds for either yourself , or from having 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. hereby attest the Code "St. ndards of . truthfulness for City pl Offices, Employees and Agency Members." by Chapter 2, of the Article VII — of the e Ci ty /� //6 ra / Q � N J���� Applicants Signature Date Name of Applicant (PLEASE PRINT) Please attach a copy of your resume to this applicati NOTE: Applications will remain on file fora period of one (1) calendar year Date: _ /2010 Control No. Date: / Received in the City Clerk's Office by : Name of Deputy Clerk F: \CLER \$ALL \aFORMS\BOARD AND COMMITTEES \BC Application.doc MIAMBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www. miamibeochfl.cov CITY CLERK Office CityClerk@m i amibeachfl.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 -1 1.1(i) (2) Board Member name: 04,OL- //oostii) 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. _Le - //IA Signature: Date: il l cn T 1°i°D SOURCE OF INCOME STATEMENT Please. Print or Type First Name Middle Name /Initial Last Name Disclosure For Tax Year �,� / ! Endin f)L ) Name: �' - -5. 0 . Z-001 Mailing Address: � -+��- Ml ✓� ac,�_f / 3/// City /State /Zip: � J �. $racial .Security Number: — - Filing as a: ® County Employee: ` i ® Municipal Employee of: ,( / Position held or sought Board where serving: /) - $7 "' I/ Term or Employment i Began an: Department where employed: Work Address: If your home address is exempt from public records pursuant to Florida Statutes § 114.07 please check here (read instructions): El 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 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 � / ..O.— L 0 /� y -5t i . e i as S� iR'ct /7 g s .S ,S c I5' I hereby swear (or affirm) that th aforesa' information is a true and correct statement. Date si ned 4/ . signature of person isciosing 9