Esther Egozi Choukroun A W \ 1 B E A C
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
4/19/2011
Esther Egozi Choukroun
21 LaGorce Circle
Miami Beach, Florida 33141
Youth Center Advisory Board
Congratulations! You have been reappointed by Commissioner Michael Gongora
to the above referenced agency, board or committee for a term 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, congratulations and good luck.
Sincere) ,
,0 /5
Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
Ellen Vargas
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 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
Employees
We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community.
• -
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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 -741 1, Fax: (305) 673 -7254
TO Esther Egozi Choukroun
RE: Youth Center Advisory Board
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 o a • - ::.rd or committee on which
I serve) on July 1st, following the closing of the calendar year on v '.• I have served.
C •
Esther Egozi Choukroun
7
Sworn to and subscribed before me this day ofikt , 2011.
jice
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.
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NAME: Ei014 1� VO"-e V .
t Name irs Name Middle Initial • fciLlat--- 14 Be4, ri.... HOME ADDRESS: 2 40� C
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Apt No. House . /Street City State Zip Code
PHONE: .. W ° 0 C. - 4 14 eit LL v.
Hom Work Fax Email address
•
Business Name: Position: eiE0
Address: ' 5 biug-04.. - titedwifil,i)--?3
No. reet City State Zip Code
Professional License 11 4 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 or No
• Demonstrate an ownership /interest in a busineasZ Miami Beach for a minimum of six (6) months: Yes or.No "
• Are you a registered voter in Miami Beach es or No .-,
• (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 •r 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)
Affordable Housing Advisory Committee Marine Authority
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 Government 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
Health Advisory Committee Waterfront Protection Committee
Health Facilities Authority Board,.- - Youth Center Advisory Board I. %J
Hispanic Affairs Committee
Historic Preservation Board
Housing Authority
Loan Review Committee *Board Required to File State Disclosure Form
N , -• ap. 0 .• for Youth Adviso :. -rd, pl :se d' ate your affiliate. • ith th : ; Scott kow ' • Center: 41 e..ervija r_riti
GA " 1. • ' 1 b
1. Past service lin the Yout enter Advisory Boa .. es No Year f Service:
2. Present participation in Youth Center activities by your childre es No . If yes, please list the names of your children, their
ages, and which programs. List below:
Child's name: Age: Program:
/ IW Child's name: 1 e ��•- Age: Program: sci_sek. 4
F. \CLER \$ALL \aFORMS \BOARD AND COMMITTEES \BC Application,doc 4F-
•Have you ever been convicted of a felony: Yes r No If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes or No , If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes or No . If ex , es explain in detail
Y p
• Are you urrently serving on an City Boards or Committees: Yes No . If es; which board?
• What organizations in the City of Miami Beach do you currently hold membership in? im A ____
Name: Title:
Name: Title:
ist all properties *tied or have an interest in, which are located within the City of Miami Be ch
1 re itme„,,s,,,,,,. • I am now employed by the City of Miami Beach: Yes r No . Which department?
• Pursuant to City Code Section 2 - 25 (b): Do you have a parent , spouse , c , brother , or sister who is employed by the
City of Miami Beach? Check all that apply. Identify the department(s): (t,J
1 hil •
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 op 1 op reporting requirements.
Gender: Male Female
Ethnic 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 affili on or community recognition.
Physically Challenged: Yes r No .
Employment Status: Employed Retired 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 hereb _ est to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
Article d e C Code "Standards of Condtict for Ci Officers, Employees and Agency IV�ernbers."
. D.- 2- 11Pri 2'4)11 I. ' eiliner b £ 1 0 411/114 464"
Applicant's Signature Date Name of Applicant (PLEASE PRINT)
Please attach a copy of your resume to this application •
NOTE: Applications will emaiq on file for a period of one (1) calendar year.
Received in the City Clerk's Office by : _. ■ , ' 1 Date: _ / /2010 Control No.. 0 Date: _ / _ /20105c. 9 //
Name of Deputy Clerk
N
MIAM MADE
, SOURCE OF INCOME STATEMENT ,
'
Please Print or Type First Name Middle Name /Initial Last Name
fo Disclosure
S l Fo r Tax Year
Name: Ending: G�`'�-'G O
Mailing Address: )'-
LA,
OrejaL- rac...•
City /State /Zip: M IetiVt1 • CI' gi 1441
Social Security Number: _____ANIIIMOINIR______
Filing as a: ® County Employee: ' , =
0 Municipal Employee of: 14& taSai y g41P : ...€4,01,Ar
Position held or sought: 54C4/111- (.y „1 f"" ' (C go."4
Board where serving: j It ,ij __ ' ( Term or Employme
Began on: 1 20
Department where employed: 1 \1. it
Work Address: 2 - Catotttotale-01,441--
MI Af r 73 131
If your home address is exempt from public records pursuant to
Florida Statutes § 119.07 please check here (read instructions): ® Work Telephone: �i -3 "
Home Address: 2 1 11..4. psem_ O--;e■jt"--
1 1 is
Street Addre 32 %‘41 . 4f11
l V 94 Ir"
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
r rill 71 ". - 1 - rrs
K fit. -"!�lt i'l5*'*_ _ G n Ii� . AMIN ii' .7"
I hereby swe r affirm) that the aforesaid information is a true and correct statement.
...-. 62 Z •r. 11 I ..
Signature of person disclosing Date gned
( TA N\ tv\/MtBEACH
City of Miami Beach,
1 700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miamibeachfl.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: t511+1 E1.401-11 CAlli)MICA-4,WO ....
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.
--- (1 - D '
Signature: Date:
F: \CLER \$ALL \aFORMS \BOARD AND COMMITTEES \BC Application.doc