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Jeremy Glazer 12/31/2013 ® MIAMI BEACH 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: 13051 673-7411, Fax: (305) 673-7254 02-28-2012 Jeremy Glazer UBJ._ECT :l Affordable Housing Advisory Committee Congratulations! You have been appointed by the City Commission to the agency, board or committee named above for a term ending: 12/31/2013. Pursuant to Ordinance No. 2006-3543, commencing with terms beginning on or after January 1 st, 2007, the term of board members who are directly appointed by a member of the City Commission shall automatically expire on December 31 of the year the appointing elected official leaves office. If you are unable to accept this appointment or have any questions, please call the City Clerk's Office at 305-673-7411. Please read the enclosed materials carefully. Congratulations again and good luck. Sincerely, Robert Parcher City Clerk cc: Saul Frances, Parking Director Richard Bowman 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, 2-458 and 2-459 Ordinance No. 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 Employee We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community. ® MIAMI BEACH 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 Jeremy Glazer RE: Affordable Housing 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 theFlonda 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 1 st,following the closing of the calendar year on which I have served. Jeremy Glazer Sworn to and subscribed before me this 6f�day of k l2 L, 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. ®_ MIAMI BEACH CITY OF MIAMI BEACH ii BOARD AND COMMITTEE APPLICATION FORM NAME: GItZL- •Jexe'^')•l p Last Name First hame �e Middle Initial HOME ADDRESS: D �,� Leo)< � M��, C D eheL) F(, 33 k3`[ Apt No. House No./Street City /S�ttate Zip Code PHONE: �J��,�(P� •?j(PC� 1ttevlitjG�k2e.�� Vel X00:lof. Homed a Work Fax /it address Business Name: �`� `'v�'t �� Position: -z 64,\ Cah^p��-, �`� "'�, Address: S �� SW �sJ 1N�`�2 ^ �c;! }�tti�� 3312 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)(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 outh Beach Middle Beach • I am applying for an appointment because I have special abilities, knowle ge 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) XrAffordable Housing Advisory Committee ❑ Historic Preservation Board ❑Art in Public Places Committee ❑ Housinq Authority ❑ Beautification Committee ❑ Loan Review Committee ❑ Board of Adjustment* ❑Marine Authority ❑ Budget Advisory Committee ❑Miami Beach Commission for Women ❑Capital Improvements Projects Oversight Committee ❑Miami Beach Cultural Arts Council ❑Committee on the Homeless ❑Miami Beach Human Rights Committee ❑Committee for Quality Education in MB ❑Miami Beach Sister Cities Program ❑Community Development Advisory ❑ Normandy Shores Local Government Neigh. Improvement ❑Community Relations Board ❑ Parks and Recreation Facilities Board ❑ Convention Center Advisory Board ❑Personnel Board ❑ Debarment Committee ❑Plannin Board* ❑Design Review Board* ❑Police Citizens Relations Committee ❑ Disability Access Committee ❑Production Industry Council ❑ Fine Arts Board ❑Safety Committee ❑Gay, Lesbian, Bisexual and Trans ender GLBT ❑Single Fa mil Residential Review Panel ❑Golf Advisory Committee ❑Sustainability Committee ❑Health Advisory Committee ❑Transportation and Parking Committee ❑ Health Facilities Authority Board ❑Visitor and Convention Authority ❑ Hispanic Affairs Committee ❑Waterfront Protection Committee ❑Youth Center Advisory Board *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 Applicotion.doc *Have you ever been convicted of a felony: Yes❑or NoX If yes, please explain in detail: • Do you currently have a violation(s) of City of Miami Beach codes: Yes ❑ or No Vlf yes, please explain in detail: • Do you currently owe the City of Miami Beach any money: Yes ❑or Nor 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 all properties owned or have an interest in, which are located within the City of Miami Beach: k"1 1-ehox Noe . 4� q • I am now employed by the City of Miami Beach: Yes ❑or Nod(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 NoY 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). X • 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 hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2, Article VII—of the City Code"Standards of Conduct for City Officers,Employees and Agency Members." Ap can; s Sign ure IDatd Name of Applic nt(PLEASE PRINT) Received in the City Clerk's Office by: —Date:—/ /2010 Control No. Date:_/_/2010 Name of Deputy Clerk OP MIAMI BEACH City of Miami Beach, 1700 Convention Canier Drive, Miami Beach, Florida 33139, vrww miamlbeachfl.aov CfTY CLERK Office CiiyCleri C m i omibaochfl.,gov Tel: 305.673.7411 , Fax:305.673.7254 Acknowledgement of fines/suspension for Board Mere bers for failure to comply with Miami-Dade County Financial Disclosure Code Provision Code Section 2-11.1(i) (2) Board Member name: �E 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,rare -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 maybave been recently appointed. You -mustflle 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 Milami=Dade :County Code Chapter 1, General Provision, Section 1,5 may subject the person or firm to a f ne not to.exceed $500.00 or by imprisonment in the county jail for a.period not to exceed.sixty days, or both. c� l2 Signature: Date: N M® SOURCE D INCOME STATEMENT Please.Print.or Type First Name Middle Name/Initial Last Name / Disclosure For Tax Yaar Name: Mailing Address: city/State/Zip: Social.security Number: Filing as a: ® County Employee: ® Municipal Employee of: a position held or sought: Board where serving: � Term or Employment Eagan on: Departmentwhere empioyed: Work Address: if your home addreas is exempt imm public records pursuant to ® �iVoric Taia feone: Florida statutes li 119.07 piease check here(read instructions); P Horne 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 inc g m ludin public eery you cti received or any person received for your benefit or use during the disciasure period, The income of your spouse or any business partner need not be disclosed. if continued an e Lseparate sheet, check here: 0 Des criptiDn of the Principal Name of Source of Income Address guSlness AaLiv G cq ., I hereby swear (or affirm)that the aforesaid information is:a true .0nd �Drre�statement, 612 Signature pars d1r.6osing Rate signed