Antonio Hernandez, Jr. CA 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) 673-7411, Fax: (305) 673 -7254
02 -15 -2011
Antonio Hernandez Jr.
8230 Hawthorne Ave
Miami Beach, Florida 33141
ra3.4 : ;T Debarment Committee
Congratulations! You have been appointed by Commissioner Michael Gongora
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,
414/,(2.2.—frt •
Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
Gus Lopez
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.
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
TO Antonio Hernandez Jr.
RE: Debarment 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: 12/31/2012.
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 yea n which I have served.
/
An • nio Hern -- .• ez Jr.
Sworn to and subscribed before me this •ay of A 011.
P A �
Fob 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.
r
MIAMI BEACH
CITY OF MIAMI BEACH
BOARD AND COMMITTEE APPLICATION FORM
NAME: H (/iic, GC 2 JY 4,4_, uv5i�
Last Name First Name Middle Initial /
HOME ADDRESS: 5� L or-,c 4 I1(V , ��- _4 , c el
Apt No. House No. /Street City I State Zip Code
PHONE: 3D .-J ∎ s_ 4' f `CCU / 1 ( 5 35 ° ovd
(?lr AP-✓a jv
m Work / Fax Email a ess
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B Name: iC �.L- t�.�j S i LL C Position: /a,, ` 'A A/12.-6✓
Address: ae) 3 ? A tiJ ) r4 �7- _ /Iv / - C, 3 -'1 2 '
No. Street City / State Zip Code
Professional License (describe) Expires: Attach a copy of the Lcense
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 4-6r No
• Demonstrate an ownership /interest in a business in Miami Beach for a minimum of six (6) months: Yes or No V
• Are you a registered voter in Miami Beach: Yes : • •
• (Please circle one): I am now a resident of: _. 'North Beac South Beach Middle Beach
• I am applying for an appointment because : : _ - -- - . • 1 ities, knowledge and experience. Please list below: ,,77
• Are you presently a registered lobbyist with the City of Miami Beach? Yes or No " r -v�'� /u . i l'
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)
i Affordable Housing Advisory Committee ❑ Marine Authority
0 Art in Public Places Committee ❑ Miami Beach Commission for Women
❑ Beautification Committee ❑ Miami Beach Cultural Arts Council
0 Board of Adjustment' 0 Miami Beach Human Rights Committee
0 Budget Advisory Committee ❑ Miami Beach Sister Cities Program
❑ Capital Improvements Projects Oversight Committee ❑ Normandy Shores Local Government Neigh. Improvement
0 Committee on the Homeless ❑ Parks and Recreation Facilities Board
0 Committee for Quality Education in MB 0 Personnel Board
❑ Community Development Advisory ❑ Planning Board*
0 Community Relations Board ❑ Police Citizens Relations Committee
❑ Convention Center Advisory Board 0 Production Industry Council
Debarment Committee ❑ Public Safety Advisory Committee
0 Design Review Board" ❑ Safety Committee
0 Disability Access Committee ❑ Single Family Residential Review Panel
❑ Fine Arts Board ❑ Sustainability Committee
0 Gay, Lesbian, Bisexual and Transgender (GLBT) ❑ Transportation and Parking Committee
❑ Golf Advisory Committee ❑ Visitor and Convention Authority
❑ Health Advisory Committee ❑ Waterfront Protection Committee
0 Health Facilities Authority Board ❑ Youth Center Advisory Board
❑ Hispanic Affairs Committee
0 Historic Preservation Board
❑ Housing Authority
❑ Loan Review Committee *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 21 No LI Years of Service:
2. Present participation in Youth Center activities by your children Yesi_; 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:
F:ACi.ER \$Al.t \aFORMS1BOARD AND COMMITTEES yvBC Apziicoflon.cloc
•Have you ever been convicted of a felony: Yes or No ii yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes or No `' If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes ` ! or No .3( If yes, explain in detail
• Arrou current serving on any City Boards or Committees: Yes Noe. If yes; which board?
r
'c e cA f ■e-ia■) Cc, — )r? f /
• 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:
• I am now employed by the City of Miami Beach: Yes 0 or Noij. Which department?
• Pursuant to City Code Section 2 -25 (b): Do you have a parent espouse __I, child brother 0, or sister 0 who is employed by the
City of Mia I each? Chekk all that apply. Identify he d partment(s ):
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: AtiVlale ❑ Female
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.
iHispanic: 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: Employedlr Retired 0 Homemaker ❑ Other 0
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,
Artic • V - • • Ci .de "Standards of Conduct for City Officers, Employees and Agency Members. "
Date Name of Applicant (PLEASE PRINT)]
Received in the City Clerk's Office by . 4 Dater / `9 !0 10 ontrol No. Date: /_/2010
Name of Deputy Clerk
•
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: / it r 1Z � PXh w, 2 / 3-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 $500.00 or by imprisonment
in the county jail for a period not to exceed sixty days, or both.
( K/f /
Signatur . Date:
F:\CLER1$ALL1aFORMMOARD AND COMMITTEESOC Application.doc
MIA M hDADE
SOURCE OF INCOME STATEMENT
Please Print or Type First Name Middle Name /Initial Last Name
Disclosure
/ For Tax Year
Name: � "�� / ! ,��^ 4,2 ✓y � Ending:
Mailing Address: 723.o 11o1w l tiu.c.tt-
City /State /Zip: l,r�l £P� -E," l Pt
J"l -
Filing as a: D County Employee:
D Municipal Employee of:
Position held or sought:
Board where serving: / el Ter or r Employ ent
Began on: /
Department where employed: Pik
Work Address: 2 3 7 /v tAJ a7 T / ` / /--11 #1. 3340
�
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: 2 3 U /40- ,,iv
Street Addrs �� J
Mtn y
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 f Source of Income Address Business Acti
)' 3 1 NAV) 7 ' L A-.�.� l je. .T r ;-....9�N s zs
I hereby ear (or affirm) that the aforesaid information is a true and correct statement.
( 17//
Signature of p disclosing
Date signed