Jeannette Egozi 12/31/2013 m I A.M EAC
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) 673-741 1, Fax: (305)673-7254
1/4/2012
Jeannette Egozi
7320 Gary Ave
Miami Beach, Florida 33141
iSU,BJaECj,
Safety Committee
Congratulations! You have been reappointed by Commissioner Michael G6ngora
to the.above referenced agency, board or committee for a term ending: 1213112013.
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
Clifford Leonard
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.
IM MIAMBEACH
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 Jeannettee Egozi
RE: Safety Committee
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 theFlor/da 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, 1 must comply with the financial disclosure*require-
ments of Miami-Dade County or the State of Florida (de ending on the board or committee on which
I serve)on July 1st,following the closing of the cal ndar year which I have served.
Jeannettee Egozi
Sworn to and subscribed before me this
day of - 2012.
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.
'XMIK-ACH
FAWAI BEACH
/B �ARD\AND (r.'ONIMITTEE AP%' ICATKIN FORNAME: 0 U W��
Las First Name M' dle Initial
HOME ADDRESS: A
Apt No House Nb./Strii-et City ate Zip C,9de
PHONE: 3,)� I �q aVlao oft f_ (I,
Hom Work Fax "mail add—ress
Business Name: t MC,�� �� i A� - Position:_
Address: � o I ' �Of *Aluml 6&JA 1-11
No Street ate Zip Code
f
Professional License(describe) k-� 'itlypires: laih a copy tile hcpnse
2-P
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.
o Resident of Miami Beach for a minimum of six(6)months:Yes❑or No ❑
• 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
o I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
e 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 ❑Housing Authority
❑Art in Public Places Committee ❑Loan Review Committee
❑Beautification Committee ❑Marine Authority
❑Board of Adjustment* ❑Miami Beach Commission for Women
❑Budget Advisory Committee ❑Miami Beach Cultural Arts Council
❑Capital Improvements Projects Oversight Committee ❑Miami Beach Sister Cities Program
❑Committee on the Homeless ❑Normand Shores Local Government Neigh. Improvement
❑Committee for Quality Education in MB ❑Parks and Recreation Facilities Board
❑Community Development Advisory ❑Personnel Board
❑Community Relations Board ❑Planning Board*
❑Convention Center Advisory Board ❑Police Citizens Relations Committee
❑Debarment Committee ❑Production Industry Council
❑Design Review Board* ❑Public Safety Advisory Committee
0 Disability Access Committee ?I-6afety Committee
❑Fine Arts Board ❑Single Family Residential Review Panel
❑Gay, Lesbian, Bisexual and Trans ender(GLBT) ❑Sustainability Committee
❑Golf Advisory Committee ❑Transparency Reliability&Accountability Committee"TRAC"
❑Health Advisory Committee ❑Transportation and Parking Committee
❑Health Facilities Authority Board ❑Visitor and Convention Authority
❑Hispanic Affairs Committee ❑Waterfront Protection Committee
❑Historic Preservation Board ❑Youth Center Advisory Board
*Board Required to File State Disclosure Form
Note: If applying for Youth Advisory Board, please indicate your affiliation with the Scoff 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 E. If yes, ple ase list the names of your children, their
ages,and which programs. List below:
Child's name: Age: Program:
Child's name: Age: Program:
F:',ICIER',,$Al5L",(iFORi A,-\BC)AR'D AND'C0MM'1T'-E5>\BC ApF,11cai'cn06,26C19 N'l-WACC
•Have you ever been convicted of a felony: Yes❑or NKIf yes, please explain in detail:
• Do you currently have a violation(s)of City of Miami Beach codes: Yes❑or No a If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes❑or N If yes, explain in detail
• Are you currently serving on any City Boards or Committees: 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 al 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 No Which department?
• Pursuant to City Code Section 2-25(b): Do you have a parent ❑,spouse q,chi d C, brother❑,or sister❑who is employed by the
City of Miami Beach?Check all that apply. Identify the department(s): ��V)
The following information is volunta/ryand is neither part of your application nor has any bearing on your consideration for appointment. It is
being asked to comply with federa qual opportunity reporting requirements.
Gender: ❑ Male male
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❑or 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:
• Prohibition from directly or indirectly lobbying city personnel(Miami Beach City Code section 2-459).
• 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.
"I re by attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
A icle I—of the City Cod "Standards of Con uct f r City Officers, Emplo and Agency Mercers."
b }L Z 1,
App i ant's Signature Date Name o p icant(P SE PRINT)
_, _.
Please tt a copy ofyour resume to this application
NOTE Applications„will rem non file for a period of one(1),calendar year:1,19
/ t `]
Received in t e City Clerk's Office by: Date:_/ /2009 Control No. ate-_ /2009
Name of Deputf Clerk
�Qv�sc�• 0l` 19 �-� ►Z
MIAMI BEACH
city of Miami Beoch,
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www miamibeachfl.aov
CITY CLERK Office CityClerkC�miamibeachfl.gov
Tel: 305.673.741 1 , Fax: 305.673.7254
Acknowledgement of fines/suspension for Board Mein hers for.failure
to comply with Miami-Dade County Financial Disclosure Code Provision
Code .Section 2-11.1 (i) _(2)
Board Mem`c
r.name:
I understand that no .later than July 1, of .each.ye®r 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,mustflle,:eventhough you may have.been
recently appointed.
YOU must file One of1he 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 75 may subject the.person or f rm;to a H ne not to exceed
.$500:00 or by imprisonment-in the county.jall fora period n®:t to exceed sixty
days, or both.
ig ture: Dote:
u
M® SOUR.:CE OF INCOME .STi ATEME�[I
please.Print.or Type First blame N(iddle Name Initial Last Flame Disclosure
For-Tax Year
Name:
Z ( Ending; ��\
Mailing Address'
CA
City/State/.Zip:
Social.Security.Number:
Filing as a; ® county Employee:
® Municipal Employee of:
position held or sought:
Board where serving• 'Term or'Emplvy ant
vc.l ! ,pM�ri/��£ Began on:
Department vft3 a employed:
Work Address: l `l� 1 Cv
If your home address is exempt from public mends Pursuant tD `
Florida statute §.118.07 please check here(mad.instrucbuns): WocicTatephDne:
s
Hoene Address: `->
.Street Address
City State. Zip Code
Please tilt below in descending order with the largest source first, the name, salary you
principal business activity of every source of your income including Public
received or any.person received for your bansfit.or use during the disclosure,Period. 'The
income of your.spouse or;any business partner need not.be:disclosed. 'If continued on o
separate sheet, check hare:
Descrip Join of'the Principal
Address Brssiness Acti
erne of Source of Inco
Z herefby suv or affirrrb)'that the aforesaid information is:e true anti aorract statement.
Date signed
.signature of Pe discio