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Stacey Kruger 12/31/2012 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 03 -10 -2011 Stacey Kruger 400 Alton Road Miami Beach, Florida 33139 Health Advisory 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, 4e4i Robert Parcher City Clerk cc: Saul Frances, Parking Director Cliff Leonard 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 IAMI BEACH 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 Siace TO -Stacy Kruger RE: Health Advisory 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 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 which I ave served. tacy Per Sworn to and subscribed before me this /5 day . tkir 2' r . /- . ic „ 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 Disdosure Requirements. We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community. , WdA/V\1 BEH CITY OF MIAMI BEACH BOARD AND COMMITTEE APPLICATION FORM NAME: Kruger Stacey J Last Name First Name Middle Initial HOME ADDRESS: 902 400 Alton Rd. Miami Beach FL 33139 Apt No. House No. /Street City State Zip Code PHONE: 305 -439 -1456 305- 274 -4123 305- 274 -4122 sjkruger007 @gmail.com I Home Work Fax Email Address Business Name: Stacey J Kruger, MD & Associates Position: Pesident Address: 203 9035 Sunset Drive Miami FL 33173 No. Street City State Zip Code Professional License (describe): Medical Doctor Expires: 01/31/2012 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 • 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 am a medical doctor practicing in Miami since 2002 • 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 Huuainy AJv. oviy Cvu'Hi at= !Vial iiia Authv1ily 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 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 Community Development Advisory Planning 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 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 [1] Health Advisory Committee Waterfront Protection Committee Health Facilities Authority Board 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: Sr • Have.you ever been convicted of ony: No If yes, please explain .etail: • 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: 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: No 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: Female Race: White Ethnic Origin: Check one only (1) White 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 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." I Stacey Kruger agreed to the following terms on 2/3/2011 11:13:01 AM / ( i _ / / 0 't) pL! Ve" Please attach a copy of your resume to this application NOTE: Applications will remain on file for „a period of on ”. ,,, w a Received in the City Clerk's Office by: _''- `'. I 6 Date: _/ _/_ Control No fi Date:27 2 i/ Name of Deputy Clerk p Y • CURRICULUM VITAE STACEY J. KRUGER, M.D. 2/3/11 Home: 400 Alton Rd. Office: 9035 Sunset Drive Apt. 902 Suite 203 Miami Beach, FL 33139 Miami, FL 33173 (305) 439 -1456 (305) 274 -4123 sjkruger007 @gmail.com skruger@childeyecare.com EMPLOYMENT ATTENDING PHYSICIAN DEC. 2005 - PRESENT Stacey J. Kruger, M.D. & Associates, P.A. Miami, FL ATTENDING PHYSICIAN SEPT. 2002 - NOV. 2005 Pediatric Ophthalmology Consultants Miami, FL FELLOW, PEDIATRIC OPHTHALMOLOGY JULY 2001 JUNE 2002 Medical University of South Carolina Charleston, SC RESIDENT, OPHTHALMOLOGY JULY 199821 LINE 2001 Mount Sinai School of Medicine New York, NY INTERN, INTERNAL MEDICINE JULY1997JUNE1998 St. Vincent's Hospital New York, NY EDUCATION M.D. CUM LAUDE AUGUST 1993MAY1997 S. U.N.Y. Health Science Center at Brooklyn Brooklyn, NY B.A. AUGUST 1989 -MAY 1993 Washington University in Saint Louis Saint Louis, MO RESEARCH AND PUBLICATIONS Saunders, RA. Kruger SJ. Lall -Trail JK. Rust PF. A 10 year overview of double elevator weakening procedures. Archc Ophthalmol. 2007 May; 125(5): 634 -8 Kruger SJ, Wilson ME, Hutchinson AK, et al., Cataracts and Glaucoma in Patients with Oculcerebrorenal Syndrome, Arch Ophthalmol, Sep 2003; 121; 1234 -37. Jacobs MS, Kruger SJ, Peterseim MM, et al., Immediate Post -Operative Alignment as a Predictor of Long Term Alignment After Bilateral Medical Rectus Muscle Recession for Esotropia, Presented at the American Association for Pediatric Ophthalmology and Strabismus Annual Meeting, March 2003, Waikoloa, HI. Kruger SJ, Wilson ME, et al. Baerveldt Seton Implantation in the Pediatric Population, Presented at the Association for Research and Vision and Ophthalmology, Annual Meeting, May 5 -10, 2002, Ft. Lauderdale, FL • Kruger SJ, Saunders RA, et al., Lower Eyelid Deformity After Inferior Oblique Muscle Anterior Transposition, Presented at American Association for Pediatric Ophthalmology and Strabismus, annual meeting, March 20 -24, 2002, Seattle, WA. Kruger S, Mindel J, Friedman A, A Case of a Alost @ Contact Lens and Actinomyces Colonisation in an Asymptomatic Patient, Arch Ophthal, April, 2000. Independent study: Interleukin -4 production and T -cell proliferation studies via tnRNA in situ hybridization, June 1992 -May 1993. Current Projects • Infant Aphakia Treatment Study; NIH sponsored Multicenter Clinical Trial PROFESSIONAL MEMBERSHIPS • American Board of Ophthalmology; Certified June 2003 • American Association for Pediatric Ophthalmology and Strabismus; Full M ember • American Academy of Ophthalmology; Fellow • Florida Society of Ophthalmology • Miami Ophthalmology Society HOSPITAL PRIVILEGES • Miami Children's Hospital; Active • Bascom Palmer Eye Institute; Active • Joe DiMaggio Children's Hospital; Courtesy • Surgical Park Center, Miami, FL; Active REFERENCES M. EDWARD WILSONJR., MD MEDICAL UNIVERSITY OF SOUTH CAROLINA Chairman, Department of Ophthalmology (843) 792 -7622 RICHARD A. SAUNDERS, MD MEDICAL UNIVERSITY OF SOUTH CAROLINA Professor, Pediatric Ophthalmology (843) 792 -2761 EDWARD L. RAAB, MD THE MOUNT SINAI SCHOOL OF MEDICINE Professor, Pediatric Ophthalmology (212) 241 -6247 1 • - •••° , 1•10• - 11. e ,. • 0 , • • • • • • • • ' • • . . • • . • . • . . . ., . • . e e • . • • . • . • . • ' . • • • .... . ... . . . . . . • . • . ,....,.-.......--,- • ..r Y......-.......,.....-,---..--...-....-,......-■.-'-..,-..+......, 1 . ,e . • ..e.VAA, 4,44 .. ,#04. k 1 4•fr I ... C 1 % • ,: • • . .. .. . ,.. S "si • A i I' t .. A .1.' A .0 k &q.: , ' , . 1.`r f .. lEe% Sr . - • • . ,,v;":14, 0,1041N., 1 ...letar ■••:-.., ...,, ,.:.,4:4•it*A %• • ...:&:.:0...5c.:.V. -. . g 9 • :' .. kegt*.:.atsg "• ...,A1..** ....• '44., irx 1 .4 . K,.:....... , • 4 - , -:--., r I A ,, '': ,..• V ''''.0 0 14....%,, . ' ' • 1 t ' ' . 4 '!"*„* 4 • . 1 V...,,,,, .,„4.:.., - :• . 1:5•1' • •• ,, ..,,,,. *IA"' ••0 " . • ...14.K. ... ...I.• • 4... /7 • i; t %ii,..'?*::: . . '•-. 1 a. , , . • ....,‘,„....tht, • * , 4 4 , • „ .::. • . . . 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' a u) 2 m ... •••...,•.• .. 44•• • ` ' • I,;..,_. • : • . . - •• . .. . .. . • • • .. • • • . • . . • • , . . • , .. . . • • ..• • • • ' • • • • • • • • • • '.' • . , .. . . . . . .. ... . . . . . . , • " ; . . . . . . . . • , . • • . . . , . • . • • • • • • . • .„. . • • ...• • • • . • ' • • 1 M IAMBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.pov CITY CLERK Office CityClerk@miamibeachfl.gov Tel: 305.673.741 1 , 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: "4147 9 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. 67/0 3// ignature: Date: COUNTY SOURCE OF INCOMES STATEMENT Please Print or Type First Name Middle Name /Initial Last Name Disclosure Cq K Cr- For Tax Year Name: Ending: 20 I b " Mailing Address: 403 w AMor g c * 0 a City /State /Zip: )0,m1 7t `.ndtr) L S ^ 3 r: — Filing as a: © County Employee: Municipal Employee of: Position held or sought: Board where serving: reO,kPY mmsnil Term or Employment Began on: 3 -9 1 / 1v110,M V ,, Department where employed: Work Address: If your home address is exempt from public records pursuant to p�7 �- 4 / ?) Florida Statutes § 119.07 please check here (read instructions): Work Telephone: Home Address: 00 1;1 4 °I ©� Street Address T) (I '� 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 Activi Knkc r M: 4 AS I — = Pr .it I cy\\Crn■ 'F L 33f Z her • wear (or aff hat the aforesaid information is a true and correct statement. „ 3- J /1 - i • ature of pe on di iosin Date signed