Maria Hosu 06/30/2012 CA MIAMI BEACH
City of Miami Beach, 1700 Convenhon Center Drive, Miami Beach, Florida 33139, www.mramibeachfl.gov
OFFICE OF THE CITY CLERK, Robert Parcher, Cry Clerk
Tel (305) 673 -7411, Fax. (305) 673 -7254
October 12, 2011
Maria Hosu
1007 6th Street
Miami Beach, Fl 33139
SUBJECT: Committee for Quality Education in MB
Dear Ms. Hosu,
Congratulations! You have been appointed as a Representative of the PTA for South Pointe
Elementary School to the above referenced agency, board or committee for a term ending,
06/30/2012.
If you are unable to accept this appointment, please notify the City Clerk's Office at (305)
673-7411.
Sincerely, p •
)11, /a2e Ze.p.-/S Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
Leslie Rosenfeld, Liaison
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 -1 1 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 argsp/ mt7ed,,; 1pm�i(��na,g� gelle�t RubGc service and sc�fey to a!t who live, work and p rn o ur vibrant Tropical, hrstonc community
tr'c dr pUP)Fc sedge J^(} sso ety ro al ! who U ve NCrk a ;p of %a)' :n aut v ? ran r Opico), h ' J "c comm t,,>,;),
MIAMI BEACH
Cit of Miami Beach, 1700 Convention Center Drive, Miami Beach, Honda 33139, www.miamibeachfl.gov
OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk
Tel: (305) 673-7411, Fax: (305) 673 - 7254
TO Maria Hosu
RE Committee for Quality Education in MB
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' 6/30/2012.
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 /onda 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 calend r year on which I av s rved.
Maria Hosu
Sworn to and subscribed before me thisoc qq I/ day of Ck (v c� 2011.
S eto
Deputy Clerk
*Please visit the City of Miami Beach website at www.miamibeachfl.gov under City Cleric/Board and Committees
for additional information regarding the Financial Disclosure Requirements.
We are committed to providing excellent pubhc service and safety to all who live, work and play in our vibrant, tropical, historic community
m MI AM ! R F AC H CITY OF MIAMI BEACH
BOARD AND COMMITTEE APPLICATION FORM
•
NAME: IA V .K‘ /V
HOME ADDRESS: Last }e 1C!) \�� _ First Name � Middle Initial i 5.1
Apt No House No /Street TD`C f 91 City State Zip Code
PHONE: v�/.7) `JC.— ;-).) 2_ jYl 0.0 LCD U \1A :6 . :LY'M
Home Work Fax Email address
Business Name. Position.
Address
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' )4or No L.
• Demonstrate an ownership /interest in a business in Miami Beach for a minimum of six (6) months. Yes Kor No
• Are you a registered voter in Miami Beach. Yes or No A
• (Please circle one). I am now a resident of: North Beach South Beach 1 Middle Beach
• I am applying for an appointment because I have special abilities, kri0Wfi3ge aridxperience. Please list below
• Are you presently a registered lobbyist with the City of Miami Beach? Yes • 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 (3)
choices will be observed by the City Clerk's Office. (Regular Boards of City)
- Affordable Housing Advisory Committee ❑ Marine Authority
0 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
0 Budget Advisory Committee ❑ Miami Beach Sister Cities Program
❑ Capital Improvements Projects Oversight Committee ❑ Normandy Shores Local Govemment 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
❑ Hispanic Affairs Committee
❑ Historic Preservation Board
❑ Housing Authority
❑ 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 ❑ No ❑ Years of Service.
2 Present participation in Youth Center activities by your children Vest] No 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
•
i
•Have you ever been convicted of a felony Yes or NoKlf yes, please explain in detail
• Do you currently have a violation(s) of City of Miami Beach codes: Yes 7 or NO< If yes, please explain in detail'
• Do you currently owe the City of Miami Beach any money' Yes E or No\ If yes, explain in detail
• Are you currently serving on any City Boards or Committees' Yes or No E. If yes, which board?
• What organizations in the City of Miami Beach do you currently hold membership in?
'
Name Title kJ I "
Name Title.
• List all properties owned or have an interest in, which are located within the City of Miami Beach
• I am now employed by the City of Miami Beach. Yes ❑ or NgV department?
• Pursuant to City Code Section 2 -25 (b): Do you have a parent Cl, spouse 0, child 0, brother C1, or sister 0 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 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 affiliation or community recognition.
Physically Challenged: Yes 0 or N .
Employment Status Employed ❑ Retired ❑ Homemakers 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) a ,Q
Upon request, copies of these laws may be obtained from the City Clerk. 1 /1/L(//( S
"I hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
A 'cle VII — °Ji he City Code "Standards f Cond ct for City Officers, Employees and Agency Members."
Applicant's Si at e Dat /� Name of Applicant (PLEASE PRINT)
Received in the City Clerk's Office by Date r / /010 Control Nq b Date _/_/2010
lame of Dee d Clerk
[IA M I AM 1 Ei LAC H CITY OF MIAMI BEACH
BOARD AND COMMITTEE APPLICATION FORM
NAME. •
Last Name First Name Middle Initial
HOME ADDRESS:
Apt No House No /Street City State Zip Code
PHONE:
Home Work Fax Email address
Business Name Position
Address.
No Street 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 7
• Demonstrate an ownership /interest in a business in Miami Beach for a minimum of six (6) months: Yes ❑ or No ❑
• Are you a registered voter in Miami Beach: Yes ❑ 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 ❑ 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 (3)
choices will be observed by the City Clerk's Office. (Regular Boards of City)
❑ Affordable Housing Advisory Committee 0 Marine Authority
❑ Art in Public Places Committee ❑ Miami Beach Commission for Women
❑ Beautification Committee 0 Miami Beach Cultural Arts Council
❑ Board of Adjustment* 0 Miami Beach Human Rights Committee
❑ Budget Advisory Committee ❑ Miartii Beach Sister Cities Program
❑ Capital Improvements Projects Oversight Committee 0 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 0 Safety Committee
❑ Design Review Board* 0 Single Family Residential Review Panel
❑ Disability Access Committee ❑ Sustainability Committee
❑ Fine Arts Board ❑ Transportation and Parking Committee
❑ Gay, Lesbian, Bisexual and Transgender (GLBT) 0 Visitor and Convention Authority
❑ Golf Advisory Committee ❑ Youth Center Advisory Board
❑ Health Advisory Committee
❑ Health Facilities Authority Board
❑ Hispanic Affairs Committee
❑ Historic Preservation Board
❑ Housing Authority
❑ 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 ❑ No ❑ Years of Service.
2 Present participation in Youth Center activities by your children Yes❑ No ❑ 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
F \CLLR \$ALL \OFORMS \BCARD AND C:OMMI'?EES \13C Application doc
I
MIA MFDADE
SOURCE OF INCOME STATEMENT
Please Print or Type First Name Middle Name /Initial Last Name
Disclosure
C For Tax Year
Name: � Q `� 6Q 6U ' o J v\ Ending: e)
Mailing Address: '�J n ) 1\ f\ n ' L-'�I �
1
City/State /Zip: ► `� iCk tea \ -- F L d 3,3) 39
Social Security Number: "�
Filing as a: 0 County Employee:
❑ Municipal Employee of:
Position held or sought: a ,;
I
Board where serving: d os 'EL1 r [ "` j Term or Employment
I Began on:
Department where employed: A+ 1 I c
Work Address: 1v f fr- p1
If your home address is exempt from public records pursuant to eel 1 3O — (COO 3 2
Florida Statutes § 119.07 please check here (read i n ): 0 Wor(Telephone:
/
Home Address: 'I S(A I A, ' V I 4- 1 1 5
a: 7 Add 3 31 -r- t___
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: El
Description of the Principal
Name of So rct of Income Address Business Activity
I he by swear (or aurm that the aforesaid information is a true and correct statement. 1ovi Signature of person disclosing Date sign 1
MIAMI BEACH
City of Miami Beach,
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www. mia mlbeachfI.00v
CITY CLERK Office CityClerkCmiamibeochfl.gov
Tel. 305.673.741 1 , Fax. 305.673.7254
Acknowledgement of fines /suspension far Board Mem bars for failure
to comply with Miami -Dade County Financial Disclosure Code Provision
Code Section 2 -1 1.1(i) (2)
Board Member name: M C k 0. •
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
recent 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( orj
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.
NK , ‘ A \u , leD'kk OPIA1) oc(
Signature: Date:
II