Barbara Gotlinsky City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
OFFICE OF THE CITY CLERK, Rafael Granada, City Clerk
Tel: (305) 673-7411, Fax: (305)673-7254
08-10-2012
Barbara Gotlinsky
,SUBJECT Disability Access Committee
Congratulations! You have been appointed by Commissioner Ed Tobin
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, 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,
Rafael E. Granado
City Clerk
cc: Saul Frances, Parking Director
Duane Knecht
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 ee Em to
P Y
We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community.
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov
OFFICE OF THE CITY CLERK, Rafael Granada,City Clerk
Tel: (305)673-7411, Fax: (305)673-7254
TO: Barbara Gotlinsky
RE: Disability Access 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 Code of
Ethics Ordinance), as well as the Florida 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* requirements of Miami-Dade County or the State of Florida (depending on the board or
committee on which I serve) on July 1, following the closing of the calendar year on which I have
served.
1;'�� A&44d
Barbara G6tlinsky
Sworn to and subscribed before me this 7 day of hmi?2(012.^
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 Requirement.
I'
{
We are committed to providing excellent public service and safety to all who live, work and ploy in our vibrant, tropical, historic community.
A
\/M I B EAC H IGI 1 71"Y 0 F VNI i A PAII B E A C H
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&;1D,�)4RD AND COMMITTI—E.E., A'PPLPNC�ATi0N-1 FOR
NAME: j5ow.,64e/9 is
Last Name First Name Middle Initial
HOME ADDRESS:- 4 J.1/11C. Atl/; ,t /I /96�' l;q 4VI-1 1E -F'Ri 347
Apt No. Hou§e No./Streel - city State Zip Code
PHONE: _Go�r_ -1-19 ult as&Too
Home Work Sa*.— Email address
Business Name: 6e-e-en 6 — Position: V P
Address:- A 4V "J'g-jac-14 B:�
,O� f
No. Street City State Zip Code
Professional License(describe) Expires: AN'Mach a-,,oZoy 011.rtle i!cevse
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 P/Or No ❑
• Demonstrate an ownership/interest in a business in or iami Beach for a minimum of six(6)months:Yes Jdr No ❑
�_'MI
N
•Are you a registered voter in Miami Beach: Yes V o Ej
• (Please circle one): I am now a resident of: North Beach vb4outh 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)
A.,
Affordable Housing Advisory Committee ❑ Historic Preservation Board
❑Art in Public Places Committee ousin g 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
V_ 0 Personnel Board
i-Convention Center Advisory Board
❑ Debarment Committee ❑ Planning Board*
❑Design Review Board* ❑ Police Citizens Relations Committee
godisability Access Committee ❑ Production Industry Council
❑ Fine Arts Board ❑Safety Committee
❑Gay, Lesbian, Bisexual and Transgender(GLBT) ❑Single Family 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 or Youth Advisory Board, please indicate your affiliation with the Scoff Rakow Youth Center:
1. Past service on the Youth Center Advisory Yes❑No❑ Years of Service:
Center Yes 11 N Years of Seorvi,,ce
t r
C Y
2. Present participation in Youth Center activities by yo dren Yeso No cl. If yes, please list the names of your children, their
ages,and which programs. List below:
Child's name: Age: rogram:
A".. P r,,,,r5�r".
Child's name- Age: Program:
AN
t
*Have you ever been convicted of a felony:Yes 0 or No 4-1<yes, please explain in detail:
• Do you currently have a violation(s)of City of Miami Beach codes: Yes 0 or No 0"ryes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes❑or No Je yes, explain in detail
•Are you currently serving on any City Boards or Committees: Yes []or No eyes; which board?
•What organizations in the Ci of Miami Beach d ou currently hold me b rship i ?
Name: r� 6 tle: �
Name: L)44 a itle:
�4-4&#T - %01
• List all properties owned or have an interest in, w is are located within the City of Miami Beach:
110 i
• I am now employed y the City of Miami Beach: Yes ❑or Nom-<hich department?
• Pursuant to City Code Section 2-25(b): Do you have a parent 110,spouse❑,child❑,brother 0,or sister❑who is employed by the
City of Miami Beach?Check all that apply. Identify the department(s): Ail
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 -male
Ethnic Origin: Check one only(1)
901hite (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 NoI-iL/
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 Clerk.
"I hereby attest to the accur cy and truthfulness of the application and have received, read and will abide by Chapter 2,
Arti II- f the City CWtan ards of Conduct for Cit Officers,Em loyees and Agency Members."
licant's Signature Date ame of Applicant(PLEASE PRINT)
Received in the City Clerk's Office by: Date:_/ /20 0 Control No.� Date:_ /2010 �-
Name of Deput Clerk
,M A�\A 1 B EAC H
City of Miami Beach,
1 700 Convention Center Drive,
Miami Beach,Florida 33139,
www.miamibeochfl.gov
CITY CLERK Office CityClerk @miamibeachfl.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: „_iJ,
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 firm to a fine not to exceed $500.00 or by imprisonment
in the county jail for a period not to exceed sixty days, or both.
X Aft
Si ature: Date:
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application.doc
►®°►�°� SOURCE OF INCOME STATEMENT
Please Print or Type First game Middle Name/Initial Last Name Disclosure
For Tax Year
Warne: �l 0�- U' Ending:
Mailing Address:
City/State/Zip:
Filing as a: ® County Employee:
® Municipal Employee of: —
Position held or sought:
Board where serving: /S � -e.e cS S Teruo or Employment Began 7�
Began ®n: Q I 7
Department where employed:
Work Address:
if your home address is exempt from public records pursuant to Work Telephone:
Florida statutes§119.07 please check here(read instructions): p
Borne Address:
Street Address
city State Zip Code
Please list below in descending order with the largest source first, the name, address and
principal business activity of every source of your income including public salary you
received or any person received for your benefit or use during the disclosure
�f continrued.on ha
income of your spouse or any business partner nee d not be disclosed.
separate sheet,check here:
Description of the Principal
Name of Source of income Address Business Activi
r$en F v f r Y
C!4 3
I hereby swear(or affirms)that the aforesaid information is a true and correct statement.
/�S Signature of pers4losing
Date signed