Loren Pearson 12/31/2012 el MI 4, t\A R
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
03 -11 -2011
Loren Pearson
551 Lakeview Drive
Miami Beach, Florida 33140
$0134,E04,, NY,' Police Citizens Relations 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,
Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
Chief Carlos Noriega
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.
t\A
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 Loren D. Pearson
RE: Police Citizens Relations 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 cale dar year on which ave served.
.
oven D. Pearson
61
Sworn to and subscribed before me this day of � "; 20 1.
f
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 safely to all who live, work and play in our vibrant, tropical, historic community.
A 1
40
CITY OF MIAMI BEACH
______ M AAA BEillkC H
"....„."...
BOARD AND COMMITTEE APPLICATION FORM
NAME: Pearson Loren D
Last Name First Name Middle Initial
HOME ADDRESS: 551 Lakeview Drive Miami Beach FL 33140
Apt No. House No. /Street City State Zip Code
PHONE: (305)467 - 5240 (305)567 - 5576 (305)567 - 9343 LDP @AssoulineBerlowe.com
Home Work Fax Email Address
Business Name: Assouline & Berlowe, P.A. Position: Attorney
Address: 308 3250 Mary Street Miami FL 33133 -5232
No. Street City State Zip Code
Professional License (describe): Florida Bar 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
• 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: Middle Beach
• I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
Member of the Florida Bar, Parent of a child attending North Beach Elementary
• 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)
Affui dalik Huubi► iy Adviaur y Cu i n i iill= Huubii iy Authui ity
Art in Public Places Committee Loan Review Committee
Beautification Committee Marine Authority
Board of Adjustment* Miami Beach Commission for Women
Budget Advisory Committee Miami Beach Cultural Arts Council
Capital Improvements Projects Oversight Committee Miami Beach Sister Cities Program
Committee on the Homeless Normand Shores Local Gov't Nei • h. Im. rovement
[1] Committee for Quality Education in MB Parks and Recreation Facilities Board
—
Community Development Advisory Personnel Board
Community Relations Board Planning Board*
Convention Center Advisory Board Police Citizens Relations Committee
Debarment Committee Production Industry Council
Design Review Board* Public Safety Advisory Committee
Disability Access Committee Safety Committee
Fine Arts Board Single Family Residential Review Panel
Gay, Lesbian, Bisexual and Transgender (GLBT) Sustainability Committee
Golf Advisory Committee Transportation and Parking Committee
Health Advisory Committee Visitor and Convention Authority
Health Facilities Authority Board Waterfront Protection Committee
Hispanic Affairs Committee Youth Center Advisory Board
Historic Preservation Board
* 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: No 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: Yph
Child's name: Age: Program:
Have you ever been convicted ofOIony: 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 Y es; which board?
• What organizations in the City of Miami Beach do you currently hold membership in?
Name: BNI Miami Beach Title: Member
Name: La Gorce Country Club Title: Member
• List all properties owned or have an interest in, which are located within the City of Miami Beach:
551 Lakeview Drive
• 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: Male 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 Loren Pearson agreed to the following terms on 1/6/2011 3:38:47 PM r
Please attach a copy of your resume to this application
NOTE: Applications will remain on file for a period of one 1) calendar year.
/�
Received in the City Clerk's Office by: >C
� ✓ � Date:( / t�✓ /7 Control N Date: /(
Name of Deputy Clerk
M !AM BEACH
City of Miami Beach,
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miamibeachfl.gov
CITY CLERK Office CityClerk @m i amibeachfl.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:
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 havebeen
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.
i]i /20
Signature: Dote:
MIA M I•DADE
SOURCE OF INCOME STATEMENT
Please Print or Type First Name Middle Name /Initial Last Name
Disclosure
Loe\ D A, VeacSOn For Tax Year Name: Ending: ��
Mailing Address: 5S 1 Lc \Q_U eA.n1 \J r; Ve
City /State /Zip: K‘\aty-i\
"eC CSn E 3 I L
Social Security Number:
Filing as a: ® County Employee:
® Municipal Employee of:
Position held or sought:
Board where serving: . (1,1s Re Ii i ; (Oyf -Ferro or Employment
T Began on:
Department where employed:
Work Address:
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:
5 Lul<e ev�J
M can ( E each t_
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
P 5scaty v t d- ,PFD X250 MQa 'qo 4 idml Lain F �r
Lor a�. rr
r atc ?ccitsbv PA 32 Q 50 (via lgo`1 Mlcn I La vv 1-Ir h1
L% \cr Pea s),, ft) � PA T" 1Y* Uo2C71 MB I R 33N10 F;f4 /1
I her by swear (o irm) that the aforesaid information is a true and correct statement.
/ 77 /
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Signature of erson disclosing Dat signed