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Tony Trujillo 12/31/2012 CA ,fA,IAMI BEA H 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 03 -10 -2011 Tony Trujillo 1000 South Pointe Drive Apt. 2104 Miami, Florida 33139 Capital Improvements Projects Oversight Committee 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, D Z Robert Parcher City Clerk cc: Saul Frances, Parking 4'rector George Gomez V 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 MIAMIBEAH Cit of Miami Beach, 1700 Convention Center Drive, Miami Beach, Horida 33139, www.miamibeachfl.gov OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk Tel: (305) 673 -7411, Fax: (305) 673 -7254 TO Tony Trujillo RE: Capital Improvements Projects Oversight 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 (depen on the board or committee on which I serve) on July 1st, following the closing of the calendar r on which I have served. t Ton T rujillo / Sworn to and subscribed before me this A4' day of /Y/ �1, 2011. c ? ael.44CePo.)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. I trk r e M IAi\AI B CITY OF MIAMI BEACH BOARD AND COMMITTEE APPLICATION FORM NAME: Trujillo Tony A Last Name First Name Middle Initial HOME ADDRESS: 2104 1000 South Pointe Drive Miami Beach FL 33139 Apt No. House No. /Street City State Zip Code PHONE: 305 873 3992 305 428 5545 ttrujilio @pankey.org Home Work Fax Email Address Business Name: Pankey Institute Position: President & CEO Address: One Crandon Blvd Key Biscayne FL 33149 No. Street City State Zip Code Professional o essional 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 ownershipfinterest 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 • Demonstrate an ownership /interest in a business in Miami Beach for a minimum of six (6) months: No • Are you a registered voter in Miami Beach: Yes • (Please circle one): I am now a resident of: South Beach • I am applying for an appointment because I have special abilities, knowledge and experience. Please list below: I have overseen capital building projects and have great interest in this area at the municipal level. • Are you presently a registered lobbyist with the City of Miami Beach? No 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) AffvlJaLle Hvuaiiiy AJvi auiy Cun Mcuille Authuiily Art in Public Places Committee Miami Beach Commission for Women Beautification Committee Miami Beach Cultural Arts Council Board of Adjustment* Miami Beach Human Rights Committee Budget Advisory Committee Miami Beach Sister Cities Program [1] Capital Improvements Projects Oversight Committee Normandy Shores Local Gov't Neigh. Improvement Committee on the Homeless Parks and Recreation Facilities Board Committee for Quality Education in MB Personnel Board Communi Develo • ment Adviso Plannin• Board* Community Relations Board Police Citizens Relations Committee Convention Center Advisory Board Production Industry Council Debarment Committee Public Safety Advisory Committee Design Review Board* Safety Committee 1 Disability Access Committee Single Family Residential Review Panel Fine Arts Board Sustainability Committee Gay, Lesbian, Bisexual and Transgender (GLBT) Transportation and Parking Committee Golf Advisory Committee Visitor and Convention Authority Health Advisory Committee Waterfront Protection Committee Health Facilities Authority Board f Youth Center Advisory Board Hispanic Affairs Committee 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: Years of Service: 2. Present participation in Youth Center activities by your children 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: (� i • Have you ever been convicted of a felony: No If yes, please explain in detail: • Do you currently have a violation(s) of City of Miami Beach codes: No If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money: No If yes, explain in detail • Are you currently serving on any City Boards or Committees: No If yes; which board? • What organizations in the City of Miami Beach do you currently hold membership in? Name: SoFiK9 Title: ECOMB Name: SOFNA Title: • List all properties owned or have an interest in, which are located within the City of Miami Beach: Apt. 2104, 1000 South Pointe Drive • I am now employed by the City of Miami Beach: Which department? • Pursuant to City Code Section 2 -25 (b): Do you have a who is employed by the City of Miami Beach? Check all that apply. Identify the department(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: Male Race: White Ethnic Origin: Check one only (1) Hispanic Physically Challenged: No Employment Status: Employed 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 truthfulne s 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." I Tony Trujillo agreed to the following terms on 1/25/2011 2:29:12 PM 0 ? ch a copy of your resume to this application 3 .i pplications will remain on file for a period of on ) calendar year Received in the City Clerk's Office by: / 7--(- ' Date: / /- I / Control No. ) Date: l /? s /` Name of Deputy Clerk 1 1 MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.pov CITY CLERK Office CityClerk©miamibeochfl.gov Tel: 305.673.7411 , Fax: 305.673.7254 1 Acknowledgement of fines /suspension for Board Members for failure to comply with Miamli -Dade County Financial Disclosure Code Provision Code Section 2 -1 1.1(i) (2) Board Member name: ( o A[ d L () i ( to 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 ofthe 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 fora period not to exceed sixty days, or both. A -----::2--- /S / 77let. ii Signature: Date: 1J r \ cmay oo SOURCE OF INCOME STATEMENT Please Print or Type First Name Middle Name /Initial Last Name r , �- Disclosure �� v Far Tax Year Y Name: � CJ� f-. l rL'J 1 E ndi ng: Z Q / D Mailing Address: / O dd ✓)L / J 1 () r , r � t')( / # 2 1 0 `7 City /State /Zip: `" t Social Security Number: — — Filing as a: ® County Employee: Municipal Employee of: Position held or sought: Board where serving: /' ��� yoW Term or Employment Began on: / Yi • Department were employ - : Work Address: If your home address is exempt from public records pursuant to Florida Statutes § 119.07 please check hare (read instructions): 0 Work Telephone: Home Address: A .- 52 . Street Address City State Zip Code Please fist 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 recei ed for your benefit or use during the disclosure period. The income of your spouse or a business partner need not be disclosed. If continued on a separate sheet, check here: D J Description of the Principal Name of Source of .Income Address Business Activity 1 -(4-il�� I herswear (or affirm) th the aforesaid information is a true and correct statement. riei CA. Signature of o on disclosing Date signed