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Edison Farrow 12/31/2013 ® MIAMBEACH City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www miamibeochfl.aov OFFICE OF THE CITY CLERK, Robert Parcher,City Clerk Tel: (305)673-7411, Fax: (305)673-7254 12/27/2011 Edison Farrow 536 14th Street#105 Miami Beach, Florida 33139 ±S,U,BJ.ECM Gay, Lesbian, Bisexual and Transgender Congratulations! You have.been reappointed by Commissioner Merry Libbin to the above referenced agency, board or committee for a term ending: 12/31/2013. 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. Sincerely, Robert Parcher . City Clerk cc: Saul Frances, Parking Director Rebecca Wakefield 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 safely to all who live, work and play in our vibrant, tropical, historic community. m AAIA I BEACH City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.aov OFFICE OF THE CITY CLERK, Robert Parcher,City Clerk Tel: (305)673-7411, Fax: (305)673-7254 TO Edison Farrow RE: Gay, Lesbian, Bisexual and Transgender(GLBT) 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: 12/31/2013. 1 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 theFlorida 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 n which I have served. Edison Farrow Sworn to and subscribed before me this fv day of 2012. c Silvia P eto 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. m MIAMI BEACH CITY OF MIAMI BEACH PP..i BOARD AND COMMITTEE APPLICATION FORM NAME: y Last Name (� Firsj Name Middle Initial HOME ADDRESS#1 C7 Apt No. t ' �y /H;ouse No./Street 1 City r State Zip Co/de PHONE: �®� 4 q e — 0"l�� �l`t Lcy - (x,r r cW Home ,� C Work 7 Fax (Email address c Business Name: 0'Ge- Jo Positiom: Address: No. Street City S ate 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 ownershipfrnterest forrrN0 inimum of six months in a business established in the city. •Resident of Miami Beach for a minimum of six(6)months:Yes ❑ .Demonstrate an ownershipinterest 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 Vor No ❑ •(Please circle one):I am now a resident ot. North Beach oath Bea � Middle Beach •I am a pl ing for an appointment because J have s a1abilities,�Cno experience.Please list below: P-CA• Are YOU-pre�ent�a terredd lobbyisf wiMh the Cify of Miaa li Beach? es ro Please list your preferences in order of ranking[1]first choice[2]second choice,and[3]third choice. Please note that only three(31 choices will be observed by the City Cleric'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 ❑Sustainabil' Committee a , Lesbian, Bisexual and Tran ender 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 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: FACLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application.doc •Have you ever been convicted of a felony: Yes❑or No❑(,Byes, please explain in detail: • Do you currently have a violation(s)of City of Miami Beach codes: Yes❑or No f yes, please explain in detail: • Do you currently owe the City of Miami Beach any money: Yes❑or No . If yes,explain in detail •Arer currently servi on any City Boards or Qom ittees: Yes or No❑. If yes;which board? •What organizations in the City of Miami Beach do you currently hold membership in? Name: Title: Name: Title: • List all properties owned or have an interest in,whic W located wlthi the City of Miami Beach: • I am now employed by the City of Miami Beach:Yes❑or Nod,4hich 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): W 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: V'Male ❑ Female Z h/pic 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 Guttural identification through tribal affiliation or community recognition. Physically Challenged: Yes❑or NOU. Employment Status: Employed Retired❑ Homemaker❑ Other❑ NOTE: If appointed,you will be required to follow certain laws which apply to city board/commRtee 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). • 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). • 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. "1 hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2, A II—of the Ct Code"Standards of Co duct or City Officers,Employees and Agency Members." Appl ra is Signature D to Name of Applicant(PLEASE PRINT) 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: Date:_/ /2010 Control No. Date:_/ 12010 Name of Deputy Clerk OD MIAMI BEACH City of Miami Beach, 1 700 Convention Center Drive, Miami Beach,Florida 33139, www.miamibeachfl.00v CITY CLERK Office CityClerk nniamibeachfl.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: 8A srco�j 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 form 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. C 1 / 0 IZ Sign cl fure: Date: F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application.doc MI A M FDADE SOURCE OF INCOME STATEMENT Please Print or Type First Name Middle Name Initial Last Name Disclosure For Tax Year Name: 66 "`� Ending: Mailing Address: City/State/Zip: (Ck eG•C V\ ��- 3 t 3 Q Social Security Number: - Filing as a: M County Employee: ® Municipal Employee of: Position held or sought: Board where serving: 'r��s or Employment an on: Department where employed: [ �^^, �J Work Address: IS-36 I `(� S�eQ,� W105 n-\-(A ' l-�l� If your home address is exempt from public records pursuant to ( ��/�� Florida Statutes§119.07 please chedc here(read instructions): ® Work Telephone• l Home Address: Street Addsess city State Zip Code Please list below in descending order with the largest source firs,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 A I herebm swear or affirm)that the aforesaid information is a true and correct statement. Sig re of person Aesclosing Da signed