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Harvey Burstein 12/31/2013 m MIA , 1BEAC City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachLgov OFFICE OF THE CITY CLERK, Robert Parcher,City Clerk Tel: (305) 673-7411, Fax: (305) 673-7254 1/12/2012 Harvey Burstein 1775 Washington Ave PH2 Miami Beach, Florida 33139 JT: Community Development Advisory Commit Congratulations! You have been reappointed by Commissioner Ed Tobin to the above referenced agency, board or committee for a term ending: 12131/2013. 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 Brian Gillis 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 MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeacbL= OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk Tel: (305)673-7411, Fax: )305)673-7254 TO Harvey Burstein RE: Community Development Advisory 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 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 on ich I have sery d. Harvey Burstein Sworn to and subscribed before me this day of �tN1! , 2012. _ _- FpQ—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. ® /\A I A/\A I U EAC 1 I CITY OF MIAMI BEACH BOARD AND COMMITTEE APPLICATION FORM NAME: j L_ a _ q La e o� First N me Middle Initi I HOME ADDRESS: v� Q �/r ✓ �� Wt No. Ho,vsee No/Street CRY State Zip Code PHONE: c �6 f-- S—� r — 2 T T Home Work / Fax Email address Business Name�/�f i Tom' ^ �y�- `I 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 I or No ❑ • Demonstrate an ownershipfinterest in a busi ess to Miami Beach for a minimum of six(6) months:Ye*i or NQ,❑ P ., •Are you a registered voter in Miami Beach:Ye*❑or No ❑ � • (Please circle one): I am now a resident of North Beac �Wedge h Middle Beach % • I am applying for an appointment because I have special abiliti , and experience. Please list below: •Are you presently a registered lobbyist with the City of Miami Beach?Yes❑or No g �� J Please list your preferences in order of ranking [1]first choice [2] second choice, and [3]third choice. Please note that or&thre'b- 31 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 Nei ImV&ver66nt ❑Committee on the Homeless ❑Parks and Recreation Facilities Board ❑Committee for Quality Education in MB ❑Personnel Board vCCommunity Development Advisory ❑Planning Board* ❑Community Relations Board ❑Police Citizens Relations Committee l ❑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 r, ❑Fine Arts Board ❑Sustainability Committee ❑Gay,Lesbian,Bisexual and Trans 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 fS(If 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 If yes, explain in detail •Are you currently serving on any City Boards or Committees: Yes ❑or N If yes; which board? • What organizations in the City of Miami Beach do you currently hold membership in? Name: 9p Title: 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 . Which 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): 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❑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: 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 Cleric. N hereby attes the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2, Article VII— the ode"Standards of Co uct r City Officers, mployees and Agency Members." rr LC rT plicant's Si nat W Date Name of Appli (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: ,rte i '. ) Date: i / 72010 Control No. Date:_/_1201 0 MIAMI BEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, vrww miaml6eachfl.aov CITY CLERK OFFice CityClerk@m i amibeochH.gov Tel: 305.673.7411 , Fax: 305.673.7254 /acknowledgement of fines/suspension for Board Mern bars for.failure to comply with Miami-Dade County Financial.Disclosure Code Provision Code Section 2-11.1(i) (2) Board Member name. I understand that no later than July 1, of each year all members of.Boards and Committees of the .City of Miami Beach, indiuding 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,mustflie,: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, Fiorida,.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 Z may subject the person or firm to a f ne not-to exceed . 500.00 or by imprisonment-in the county.jail fora period ncat to exceed sixty .days, or both. Signatu e Date: I M I A M MADE SOURCE OF INCOME STATEMENT Please Print or Type First Name Middle Name/Initial Last Name Disclosure For Tax Year Name: e_' / Ending: Mailing Address: f/�� ✓ 1-� � o City/State/Zip: Social Security Number: — N7 CD Filing as a: ® County Employee: c,; ® Municipal Employee of: CD Ty Position held or sought: cn 0 Board where serving: (f Term or Employment Began on: Department where employed: Work Address: If your home address is exempt from public records pursuant to Florida Statutes§119.07 please check here(read instructions): 0 Work Telephone: Home Address: Street Address 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 ,--:�Mame!#Source of Income Address Business Activity I hereby swear(0 Affirm that the aforesaid information is a true and correct statement. C" at re T.!!, lsclosing Date signed