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Adrian Raymond 10/11/2014 m► MIAMIBEACH Cit 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 02 -15 -2011 Adrian Raymond 12970 SW 2 Terrace Miami, Florida 33184 4 OE i c! ' Housing Authority Congratulations! You have been appointed by Mayor Matti Herrera Bower to the agency, board or committee named above for a term ending: 10/11/2014. 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, vc) Robert Parcher City Clerk cc: Saul Frances, Parking Director Anna Parekh 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. 1 1 m► 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 Raymond Adrian RE: Housing Authority 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: 10/11/2014. 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 /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 • - . i* have served. aymond Adrian Sworn to and subscribed before me this ke day of reio., 2011. __ Ar g : 4_ zig_t_. A c.:".„, _ C. 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. Gy / V,1 A\ Y,1 b tA`., h CITY OF MIAMI BEACH f � \ BOARD AND COMMITTEE APPLICATION FORM NAME: 1 "1 ( 1A V � 'Q 4 .A.1::. 1� Last Name first Narrie Middle Initial HOME ADDRESS: C (9 7 0 sS ( Z - 7 - e- (2 r C. g Aa ik4 L. 3 3 I SY Apt No. House No. /St t City State Zip Code PHONE: (33S 226 - 735 - 0,0 g67_z56. / /e.taZ/,kiia eAoz. �" Home, I Work 4 D F Email address Business Name: � / /0/Z 9l� Of 1 Pition: � 4 -- 7` � ,, w os / / Address: l 7./2/ N �/yJ.QN �� `� y `� / ��vt� / �j `e � Lit �C� 3� 1// No. tre et 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/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 0 or No tLI • Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes 0 or No 0* • Are you a registered voter in Miami Beach: Yes ❑ or No E • (Please circle one): I am now a resident of: North Beach South Beach Middle Beach • I am applying for an appointment because 1 have special abilities, knowledge and experience. Please list below: • Are you presently a registered lobbyist with the City of Miami Beach? Yes 0 or No ,0" 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 Affordable Housing Advisory Committee 0 Marine Authority ❑ Art in Public Places Committee 0 Miami Beach Commission for Women ❑ Beautification Committee ❑ Miami Beach Cultural Arts Council ❑ Board. of Adjustment* �� ❑ Miami Beach Human Rights Committee ❑ Budget Advisory Committee ( 2i WM - iami Beach Sister Cities Program ❑ Capital Improvements Projects Oversight Committee ❑ Normandy Shores Local Govemment Neigh. Improvement ❑ Committee on the Homeless ❑ Parks and Recreation Facilities Board ❑ Committee for Quality Education in MB ❑ Personnel Board ❑ Community Development Advisory ❑ Planning Board* 0 Community Relations Board ❑ Police Citizens Relations Committee ❑ Convention Center Advisory Board 0 Production Industry Council 0 Debarment Committee ❑ Public Safety Advisory Committee ❑ Design Review Board* 0 Safety Committee ❑ Disability Access Committee 0 Single Family Residential Review Panel 0 Fine Arts Board ❑ Sustainability Committee 0 Gay, Lesbian, Bisexual and Transgender (GLBT) 0 Transportation and Parking Committee ❑ Golf Advisory Committee 0 Visitor and Convention Authority ❑ Health Advisory Committee ❑ Waterfront Protection Committee ❑ Health Facilities Authority Board ❑ Youth Center Advisory Board x-, q 6 0 t jispanic Affairs Committee -c I tonic Preservation Board L�}'fiousing Authority Z ri 0 Loan Review Committee *Board Required to File State Disclosure Fein n C.) 'T► 1 Note: If applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Center: c 2 1. Past service on the Youth Center Advisory Board: Yes ❑ No 0 Years of Service: rn 2. Present participation in Youth Center activities by your children YesO No 0. If yes, please list the names of your children, their ages, and which programs. List below: Child's name: Age: Program: SCaflflhI, Child's name: Age: Program: a 1 A . �/I/I r 2 5 zu F \CLER`.$ALL \oFORMS \BOARD AND COMMITTEES \BC Applicotion.doc ✓ I MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office CityClerkC m i omibeochfl.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: /ii 0/ 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. • _ , re: Date: COUNTS! SOURCE OF INCOME STATEMENT Please Print or Type First Name Middle Name /Initial Last Name DisCIosure For Tax Year Name: I■DeJb � 2 t Ending LO Mailing address: C Z 1 S c) 2- City /State /Zip: t�n. --� t FL 33 IC? �f Filing as a: ® County Employee: ® Municipal Employee of: Position held or sought: Board where serving: / / 0 Began on: Department where employed: Work Address: If your home address is exempt from public records pursuant to Florida Statutes § 3.19.07 please check hare (read instructions): 0 Work Telephone: Home Address: Street Address City State Zip Code Pease 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 • UeOlk* vtF i tt .Ai 6e. (3t oU© ( /.•))0/1(X NNe - her - • - or affirm) that the aforesaid information is a true and correct statement, z /6 _! .Sign - -1. person disclosing D to sig ed