John Barker 12/3/12012 to,tAmt!, E AC H
_ 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
01/26/2011
John Barker
781 Fairway Drive
Miami Beach, -Florida 33141
tappogc-tt Golf Advisory Committee
Congratulations! You have .been reappointed by Commissioner Ed Tobin
to the above referenced agency, board or committee for a tern ending: 12/31/2012.
If you are unable to accept this appointment, please notify the City Clerk's Office :at
(305) '673-7411.
,Please read the enclosed material :carefully. Again, congratultions and igood .luck.
Sincerely, n
• /2e1 g 441l ' i2-2- /
Robert Parcher
City Clerk
1
cc: Saul Frances, Parking iDirector •
Kevin Smith
• 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, 2-26,2,2458, .2-459
Ordinance 2006-3543 - Amendment to City Code Section .2-22
Miami-Dade County Code Section_2-11:1 - Conflict of Interest and aide of Ethics Ordinance
City Wide Permit Application - (ParkingDepartment Form)
Booklet - to the Sunshine Amendment and Code of Ethics for Officers and
• Employees
We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community.
MIA/V\IBEAC]-{
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 John Barker
RE: Golf Advisory Committee
I do solemnly swear or affirm to bear true faith, loyalty and allegiance to the Government of the
United States, the 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 Commission on Ethics Gul to the Sunshine
Amendment and Code of Ethics for Public Officers and Employees, and understand that as a member
of a City of Miami Board and /or Committee, I must comply withthe financial disclosure* require-
ments of Miami -Dade County or the State of Florida (depending on the bo- d or committee on which
I serve) on July 1st, following the closing of the calendar year . w' i h. 've served.
John 'Barker
Sworn to and subscribed befo - e this 3 day of A. 2011.
1
i
oisit
p Silvia - ieto
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.
. `.r•nwwo-+*W`»*Kl -. -ter -. - v ...- r...w. t.. . -. - ewr +Y _
We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community.
A
\
NAME: Ali YteeK ab .
Last Name First Name Middle Initial
HOME ADDRESS: 781 In4J 4 (4 1 14 f 9/
Apt No. House 1<10./Street City Sta • Zip Code •
PHONE: 34S , 305 3 73- 78 joobari .cowi
Home A , Work - Fax Email address •
P
Business Name: '5 ( 01/V4 Position: DV) 5( 1-674,47
Address: J N 1 ttAri ?tL V117'atto
No. Street City State Zip Code
Professional License (describe) Expires:
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 0 or No 0
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes 0 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 CI or No 0
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)
0 Affordable Housing Advisory Committee 0 Marine Authority
0 Art in Public Places Committee 0 Miami Beach Commission for Women
• D Beautification Committee 0 Miami Beach Cultural Arts Council
0 Board of Adjustment" CI Miami Beach Human Rights Committee
0 Budget Advisory Committee D Miami Beach Sister,Cities Program
• D Capital Improvements Projects Oversight Committee • 0 Normandy 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 Community Development Advisory El Planning.Board* ,
El Community Relations Board 0 Police Citizens Relations Committee
0 Convention Center Advisory Board fl 0 Production Industry Council
D Debarment Committee •0 Public Safety Advisory Committee
0 Design Review Board* 0 Safety Committee
0 Disability,Access Committee 0 Single Family Residential Review Panel
0 Fine Arts Board • 0 Sustainability Committee
0 Gay, Lesbian, Bisexual and Transgender (GLBT) 0 Transportation and Parking Committee
is c i G i olf Advisory Committee 0 Visitor and Convention Authority
0 ealth Advisory Committee Waterfront Protection Committee •
• 0 Health Facilities Authority Board 0 Youth Center Advisory Board
ID 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 Yes[i No D. 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:
Arz.) •
•Have you ever been convicted of a felony: Yes o If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes ❑ o l . If yes, please explain in detail:
• Do you currently owe. the City of Miami Beach any money: Yes ❑ or No . if yes, explain in detail .
• Are you currently serving on any City Boar s or Committees: Yes No O. If yes; which board?
o tl
: 6 2 050 6dav
v
• What organizations in the City of Miami Beach do you currently hold membership in?
Name: Title: •
•
Name: Title:
• List all properties owned or hav�.an interest in which are located within the City of Miami Beach:
• 1 am now employed by the City of Miami Beach: Yes ❑ or NoWhich department?
• Pursuant to City Code Section 2 - 25 (b): Do you have a parent ❑, spouse ❑, child ❑, brother ❑, or sister ❑ 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: D MaIe ❑ Female
' Ethnic Origin: Check one only (1)
A White (Not of Hispanic Origin): All persons having origins in any of the original peoples of Europe, North Africa or the Middle East:
0 African - American /Black (Not of Hispanic Origin): All persons having origins in any of the Black racial groups of Africa.
❑ 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
Cultural identification through tribal affiliation or community recognition.
•
Physically Challenged: Yes ❑ or No0.
Employment Status: Employe. ,A Retired 0 Homemaker ❑ 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 VI —oft 6/City Code "Standards of Conduct for City Officers, Employees and Agency Members."
iii
, 6 - Z- ( . aolfro gadeet/
Ap ant's Signature Date • Name of Applicant (PLEASE PRINT)
Ple _ se ,. attach a ; copy of your resume to this application
- / 7
NOTE Ap- rations ul & main on for a period of;one (1)'calendar year:: f S i •
Received ,
i n the City Clerk's Office by : 4 1'; , L ,, 1� D ate: / 01 ontrol No y, I, Date: _/_/2010
Name ;•f Deputy Clerk I`
City of Miami Beach,
1 700 Convention Center Drive,
Miami Beach, Florida 33139,
www•.niiornmeacht':..ao v
CITY CLERK Office
• CityOerk @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: i Z' !�
&vke"
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" (attache d) 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.
ig . ature; Date:
F : \CLER \$ALL \aFORMS \BOARD AND COMMITTEES \BC Application.doc
•
M I A M I•DADE
SOURCE OF INCOME STATEMENT
Please Print or Type First Name Middle Name /Initial Last Name
Disclosure
N ; � keK Ending: Year
Name: g• 20/0
Mailing Address: /1. Fa:iv brive.
City /State /Zip: C c C �!. t‘Z-- 3.3, I it .)
Social Security Number:
1
Filing as a: ® County Employee:
0 Municipal Employee of:
Position held or sought: 601f Adiii5:361 NaY0(
Board where serving: S Term or Employment
Began on:
Department where employed:
Work Address: .
If your home address is exempt from public records to -- -7
Florida Statutes § 119.07 please check here (read instructions): 0 Work Telephone: � � /
Home Address: _7J /1(141r4 Af N-e.L
dd �
t Street Address
a L 33) ei 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 k`
N ame
of Source.of Income Address � �� � x = �:�� �':. .�; Business Activity
0 !gin �---
I hereby swear Or affirm) that the aforesaid information is a true and correct statement.
i of person disclosing Date signed