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Patricia M. Kaine 06/30/2012 M A M BE Cr1 City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Horida 33139, vv±, miamibeachfl.gov OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk Tel (305) 673 -7411, Fax: (305) 673 -7254 05/24/2011 Patricia M. Kaine 1717 No. Bayshore Drive 2-O Miami FL 33132 SUBIECT: COMMITTEE FOR QUALITY EDUCATION IN MIAMI BEACH Dear Ms. Kaine, Congratulations! You have been re- appointed as a Representative of the PTA for MB Senior High School to the above referenced agency, board or committee for a term ending, 6/30/2012. If you are unable to accept this appointment, please notify the City Clerk's Office at (305) 673-7411. Sincerely, Ro ert Parcher City Clerk cc: Saul Frances, Parking Director Leslie Rosenfeld, Liaison We s are \ committed to prpvidinaa public. service and, afety to whq Eve „work qnd play in our vibrant , vibrant, tropical, historic community. ` o Ore c. rn nee d �< ���'t•. r.4 e�. ��... uvD��. e c _ c •' r t :�- /v\ 1 AI\Ai BEACH CITY OF MIAMI BEACH 1 // BOARD AND COMMITTEE APPLICATION FORM 'NAME: Koine- 4+(i Cl ci, M Last Name First Name Middle Initial HOME ADDRESS: 1 '/ 1 `4 D + ` g a 0.5 Dr2 Z r . 33 , /v(.14011 GL 53)3, Apt No. ! House-No./Street City State Zip Code - PHONE: .'3 05 I / g -6 J 5 G Pea lAerg a r� � 4 . 1711Q I I , Cb rh Home Work Fax ' I Email address Business. Name , fit,- �� ' � Position: - Address: �' - No Stree'f City State Zip Code Professional 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 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 V �/ - . •. Demonstrate an ownership /interest in a business in Miami Beach for a minimum of six (6) months: Yes [8 or No ❑ . • Are you a registered voter in Miami_Beach.'Yes 0 or No C. • (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 1 1 /6 /itnk / P15, - fl aw►1 6earl , • Areyou:presently a..registered lobbyist with the. City of Miami 'Beach? Yes 0 or No 'Cd' g / P-7•A • •Please'Iist,yourpreferences in order ranking [1] first choice [2] second choice, and. [3] third choice, 'Please notethat only three (3) choices will be.observed by the City- Clerk'-s Office. (Regular Boards of City) - 0-Affordable Housing Advisory Committee - ❑ Marine Authority - 0 Art in Public Places Committee . 0 Miami Beach Commission for 'Women . - .0 .Beautification Committee 0 Miami Beach Cultural Arts Council - Board of - Adjustment* 0 Miami Beach Human Rights Committee 0.Budget Advisory Committee 0 Miami Beach Sister Cities Program ❑ Capital'dmprovementsProjects- Oversight Committee ' 0 Normandy Shores Local Government Neigh. 'Improvement 0 mmittee on the Homeless- ❑ Parks and Recreation Facilities -Board E ommittee for Quality Education in MB ❑'Personnel Board . • 0 Community Development Advisory ❑ Planning Board* 0 Community Relations Board ❑ 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* ' D Safety Committee ' 0 Disability Access. Committee 0 Single Family Residential Review Panel ID Fine Arts-Board ❑ Sustainability'Committee . ❑ Gay, .Lesbian, Bisexual and Transgender (GLBT) 0 Transportation and ParkinQCommittee '0 Golf Advisory Committee 0 Visitor and Convention Authority ,0 Health Advisory Committee 0 Waterfront Protection Committee ❑ Health 'Facilities Authority Board ❑ Youth Center Advisory Board • 0 Hispanic Affairs Committee 0 Historic Preservation.Board • ' _ al-lousing Authority - ❑.Loan Review Committee . *Board Required to File State Disclosure 'Form , Note If :applying for Youth.Advisory=Board, indicate ,your affiliation with the ScotrRakow 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 childre Ye 0 $Qa-'d. If yes, please list the names of your children, their ;ages,,and which programs. List below Child'sname: Age •Program - .Child''s-name. `/— Age Program . . F \CLER \$ALL \aFORMS \BOARD AND COMMITTEES \BC Application doc •Have you ever been convicted of a felony Yes ❑ or No r94 yes, please explain in detail • Do you currently have a violation(s) of City of Miami Beach codes Yes ❑ or No yes, please explain in detail. • .Do you currently owe the City of Miami Beach any money Yes ❑ or No r9! If yes, explain in detail • Are you currently serving on any City Boards or Committees Yes ior No 0. If yes; which board? • What organizations in the City of Mi do you currently hold membership in? Name t , Title. ', • Name. Title / • • List all properties owned or have an interest in, which are located within the City of "Miami Beach. 1 y t,o//,'n < /4 ✓�- f?'Yarn, R �u c. Gr PL 3 3/ 31 • I am now employed by the City of Miami Beach. Yes ❑ or Na/Which department? • Pursuant to City Code Section 2 (b): Do you have a parent 0, spouse 0, child 0, brother 0, or sister 0 who is employed by the City of Miami Beach? Check all that apply Identify he 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 t3 Etinic Origin:. Check one only (1) White (Not of Hispanic Origin): All persons having origins in any of the original peoples of Europe, North Africa or the Middle East. ❑ 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. ❑ 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. ❑ 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 0 or Not' / Employment Status. Employed ❑ Retired ❑ Homemaker [9' 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, rtic < VII — of the City Code "Standards of Conduct City Officers, Employees and Agency Members." icant's Signature Date N ame of Applicant (PLEASE PRINT) Received in the City Clerk's Office by Date. _/ /2010 Control No Date: !_/2010 Name of Deputy Clerk ere M1AMBEACH 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 Patricia M Kaine RE. Committee For Quality Education in Miami Beach 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. Patricia M. Kaine Sworn to and subscribed before me this 0Z day of _ta !_tiry ill 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 MIAMI BEACH City.of Miami_Beach, 1.700 Convention Center Drive, Miami Beach, .Florida 33139,, www.miamibeachff.gov 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: / , � M � 4 11 I understand that no later than ,July 1, of each year all members of'Boards :and Comrriittees of -the City of Miami Beach, including those of a .purely advisory :nature, are required to. comply with Miami -Dade CountyDisclosure Requirements. This means: that the :members of City -Advisory Boards, whose sole or primary responsibility is to recommend _legislation or;giveadvice to theCityCommission, even though ;you mayhave been recently appointed. You =,must file one of the following With the .City Clerk of Miarrii.Beach, 1700' Convention Center :Drive, Miami :Beach, Florida, :by July'l each year A "Source of Income Statement" (attached) or 2. A "Financial Statement" (attached( or] 3. A Copyof 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 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 f 51,2y /1 J Sign re Date.