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Jay Reinberg, M.D. 12/31/2012 M IAMI 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 03 -10 -2011 Jay Reinberg 3105 Sheridan Ave. Miami Beach, Florida 33140 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, S' Robert Parcher City Clerk cc: Saul Frances, Parking irector 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► 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 Jay Reinberg 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 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 _�� . 1 ' / Ja Reinberg Sworn to and subscribed before me this t 8 day of IAN , 2011. 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. ! , 4 li lil /V1 I /\/V I b tAL tl CITY OF MIAMI BEACH Reinberg, Jay E. BOARD AND COMMITTEE APPLICATION FORM NAME: Last Name First Name Middle initial HOME ADDRESS: 3105 Sheridan Avenue 33140 Apt No. House No. /Street City State Zip Code n/a 305 932 -9880 PHONE: A ,,n4-).\ "� n a ?-4 emgkoo . coni. Home Work Fax Email address Suite 2070 Doctor Business Name: Position: Address: 4302 Alton Road, Miami Beach 33140 No. Street City State Zip Code State of Florida ME 65783 Professional License (describe) Expires: Attach a copy of the license MEDICAL DOCTOR 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 aty for a minimum of six months; or b) an individual shall demonstrate ownershipfinterest for minimum of six months in a business established in the city. • Resident of Miami Beach for a minimum of six (6) months: Yes or No 0 • Demonstrate an ownershipfinterest in a business in Miami Beach for a minimum of six (6) months: Yes or No 0 • Are you a registered voter in Miami Beach: Yes 0 or No 0 • (Please circle one): I am now a resident of: North Beach South Beach Middle Beach • I am applying for an appointment because I 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 ❑ Please list your preferences In order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that only three C,1 choices will be observed by the City Clerk's Oftice. (Regular Boards of City) 0 Affordable Housing Advisory Committee 0 Marine Authority 0 Art in Public Places Committee 0 Miami Beach Commission for Women 0 Beautification Committee 0 Miami Beach Cultural Arts Council 0 Board of Adjustment' 0 Miami Beach Human RightS Committee D Budget Advisory Committee 0 Miami Beach Sister Cities Program 0 Capital Improvements Projects Oversight Committee 0 Nomzandy Shores Local Government Neigh. Improvement 0 Committee on the Homeless 0 Parks and Recreation Facilities Board 0 Committee for Quality Education In MB 0 Personnel Board 0 Commun' Develo.ment Adviso 0 Plannin. Board' 0 Community Relations Board 0 Police Citizens Relations Committee 0 Convention Center Advisory Board 0 Production Industry Council 0 Debarment Committee 0 Public Safety Advisory Committee _ 0 Design Review Board' 0 Safety Committee 0 Disabili Access Committee ❑ Sin, le Faml Residential Review Panel 0 Fine Arts Board 0 Sustainability Committee 0 Gay, Lesbian, Bisexual and Transgender (GLBT) 0 Transportation and Parking Committee 0 Goff Advisory _Committee 0 Visitor and Convention Authority Health Advisory Committee 0 Waterfront Protection Committee 0 Health Facilities Authority Board 0 Youth Center Advisory Board 0 Hispanic Affairs Committee 0 Historic Preservation Board 0 Housing Authority 0 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 0 No 0 Years of Service: 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: Child's name: Age: Program: / '✓ ..C't= ?'.SAIL \cFORMS \BOARD ANC coMMrrrEE3 \BC Acpl cotion.doc s • 4 •Have you ever been convicted of a felony: Yes 0 or No 69i yes, please explain in detail: • Do you currently have a violation(s) of City of Miami Beach codes: Yes 0 or No Lf.}Ff yes, please explain in detail: • Do you currently owe the City of Miami Beach any money: Yes 0 or No . yes, expiain in detail • Are you currently serving on any City Boards or Committees: Yes 0 or No Gf If yes; which board? • What organizations in the City of Miami B 9 ty o 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: 3105 Sheridan Avenue • i am now employed by the City of Miami Beach: Yes 0 or Notf department? • n/ a • Pursuant to City Code Section 2 -25 (b): Do you have a parent 0, spouse 0, child 0, brother 0, or sister D 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. tt is being asked to comply with federal equal opportunity reporting requirements. Gender. LI 0 Female Ethnic Origin: Check one only (1) P4Nhlte (Not of Hispanic Origin): All persona having origins in any of the original peoples of Europe, North Africa or the EAiddle East. 1 0 African- American/Black (Not of Hispanic Origin): Alt persons having origins in any of the Black racial groups of Africa. 0 Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race. 0 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. 0 American Indian or Alaskan Native: All persons having origins in any of the original peoples of North America, and who maintain Guttural iaentification through tribal affiliation or community recognition. Physically Challenged: Yes 0 or Nof Employment Status: Employed 9 Rettred 0 Homemaker 0 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 (Miaml -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 Beath 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). 1 Upon request, copies of these Taws may be obtained from the City Clerk. '1 • ereby a' =• -t to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2, • rti• e VII — • the Code "Standards of Conduct for City Officers, Employees and Agency Members." ,l 2/1/2011 Jay Reinberg Ap. n: •nat r J � \ Date Name of Applicant (PLEASE PRINT) Ple: atta. copy •'r resume to this apptication NOTE: Appll «• lons•witl vernal • n file for period f o (1) calendar year. Re served in the City Clerks Office by Zuni( ••.� r tr / Control No2A Date: / goi0 i Name of Deputy Jerk Jay E. Reinberg, MD 3105 Sheridan Avenue Miami Beach, Florida 33140 305 -469 -0145 ReinbergMD@yahoo.com Professional Work History Internal Medicine Physician 2003 - Present South Florida A»lultispecialty Association Miami Bea Florida Beach, Internal Medicine Physician 2000 -2003 Internal Medicine Associates Miami Beach, Florida Attending Physician 1997 -2000 Alt. Sinai Medical Center Miami Beach, Florida Education and Medical Training Residency Internal Medicine 07/1994- 07/1997 Mt. Sinai Medical Center Miami Beach, Florida Internship General Surgery 07/1992- 07/1993 Jackson Memorial Hospital Miami, Florida Doctor of Medicine 08/1988 - 05/1992 University of Miami School of Medicine Miami, Florida Bachelor of Arts- Economics 08/1983- 05/1987 Emory University Atlanta, Georgia Licensure and Certifications Medical License, State of Florida ME 65783 Board Certified, American Board of Internal Medicine 1997, recertification 2007 Professional Memberships American College of Physicians 1998 - Present Honors Alpha Omega Alpha Doctor- Patient Relationship Award 1992 MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.Qov 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: J ) /�J ibg 1 understand that no later than July , 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 fife, according to the Miami -Dade County Code Chapter 1, General Provision, Section 1 -5 may subject the person or fine to a fine not to exceed $500.00 or by imprisonment in the county jail fora period not to exceed sixty days, or both. ad, .v. 311111i Sig :ture: Date: • it MIAMI SOURCE OF INCOME STATEMENT Ecway Please. Print or Type First Name Middle Name /Initial Last Name Disclosure Far Tax Year �1 Name: � �e,k J��P.r �. Ending,? / C/ Mailing Address: 3\ O S -� \ c & Are. City /State /Zip: M \C n^i fe ac,-�., �L 'n l 4 Filing as a: ® County Employee: ® Municipal Employee of: Position held or sought: Board where serving: �a)7% .A1) WSW/ Term or Employment Began on: ,? // Department where employed: 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: 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 W�et(l (Alce1-l9 `-\3o0 A- 1bn (-:1 itinnC aca1,/, ) r-� 33 Z hereby swear (or affirm) that the aforesaid information is a true and correct statement. 0 jtigq s. n ure of person discinsino Date signed