Julie Zahartos City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139,www.miomibeachfl.gov
OFFICE OF THE CITY CLERK, Rafael Granado, City Clerk
Tel: (305)673-7411, Fax: (305)673-7254
November 15, 2012
Julie Zahartos
8095 NW 12th Street Ste., 300
Doral, FL 33126
SUBJECT: Health Advisor/ Committee
Congratulations! You have been confirmed by The Health Council of South Florida Inc.
(Council) as a non-voting member of the Miami Beach Health Advisory Committee.
At your convenience please stop by the City Clerk's Office to be sworn in and pick up your
package.
Sincerely,
fael E. Granado
City Clerk
City Liaison: Cliff Leonard
Saul Frances, Parking Director
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- Gu.ide 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.
i
MIAMIBEACH
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
Email CityClerk @miamibeach.gov
TO Julie Zahartos
RE: Health 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: .
I have been issued a copy of Section 2-11.1 of the Miami-Dade County Code (Confict of Interest and
Code of Ethics Ordinance), as well as the Florida Commission on Ethics Guide to the Sunshine Amend-
ment 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 ithe 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.
f
Julie Zahhartos r A�
Sworn to and subscribed before me this 3 day of k e&Al 2012.
�5
Sil is Prieto
Deputy Clerk
*Please visit the City of Miami Beach website at www.miamibeachfl.gov under City Clerk/Board and Comm
for additional information regarding the Financial Disclosure Requirement
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
BOARD AND COMMITTEE APPLICATION FORM
a�aUrS e,
Last Nam First Name Middle Initial
2 11 &i Cki Q L-J A& Ave- 20y rwa*w 313
H me Address it State Zip Code
- -ILIS) x(19 Y5-- I-W1 ' LA e- ► a
Home Telephone�� Work Telephone rr Cellular Telephone Email addr ss
_�P-G[� au,^G D�` (1 QY?(/1Gl Position 3��jorccww" S+
Business Name
p S >y� I�.`'','Sfi Sfe•34b f�l,�,� 1� 3,312-6
usiness Address 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 in ownership/interest for a minimum of six months in a business established in the city
for a minimum of six months.
• Resident of Miami Beach for a minimum of six 6 months: Yes Zor,
No
• Demonstrate an ownership/interest in a business, i 'M iami Beach for a minimum of six months: Yes or No
you a registered•Are voter in Miami Beach: Yes Z or No
• I am now a resident of: North Beach[::I South Beach Middle Beach Zh
• I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
&Y""A^ 4?a� A rtfz fA PvbK'&
•Are you presently a registered lobbyist with the City of Miami Beach?Yes Uor 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)
0 Affordable Housing Advisory Committee ❑Fine Arts Board ❑Normandy Shores Local Government
Neighborhood Improvement
❑Art in Public Places Committee 0 Gay, Lesbian, Bisexual and Transgender ❑Parks and Recreation Facilities Board
Enhancement Committee GLB
0 Beautification Committee 0 Golf Advisory Committee ❑Personnel Board
❑Board of Adjustment* Health Advisory Committee 0 Planning Board*
❑Budget Advisory Committee 0 Health Facilities Authority Board 0 Police Citizens Relations Committee
❑Capital Improvements Projects ❑Hispanic Affairs Committee ❑Production Industry Council
Oversight Committee
0 Committee on the Homeless ❑Historic Preservation Board 0 Safety Committee
0 Committee for Quality Education in MB 0 Housing Authority 0 Single Family Residential Review Panel
❑Community Development Advisory ❑Loan Review Committee ❑Sustainability Committee
0 Community Relations Board ❑Marine Authority 0 Tennis Advisory Committee
❑Convention Center Advisory Board ❑Miami Beach Commission for Women ❑Transportation and Parking Committee
❑Debarment Committee ❑Miami Beach Cultural Arts Council ❑Visitor and Convention Authority
0 Design Review Board* ❑Miami Beach Human Rights Committee ❑Youth Center Advisory Board
❑Disability Access Committee 0 Miami Beach Sister Cities Program 0 Waterfront Protection 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 U No LA Years of Service:
2. Present participation in Youth Center activities by your children Yes No�D. 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 ID or No 15?f If yes, please explain in detail:
• Do you currently have a violation(s)of City of Miami Beach codes:Yes Zh or No If 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 U&r No La. If yes;which board? �.y
S
•What organizations in the City of Miami Beach do you currently hold membership in?
lYlllr
Name Title
Name Title
• List all properties owned or have an interest in,which are located within the P4 of Miami Bea 313T
• I am now employed by the City of Miami Beach:Yes Z]or No 5ewhich department?
• Pursuant to City Code Section 2-25(b): Do you have a parent 1:1,spouse ID, child ID brother or sister ID 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.
Ethnic Origin:Check one only 1
Gen er: Male I.J Female
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.
ZIHispanic: 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,or
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 throw h tribal affilia i n or community recognition.
Physically Challenged: Yes or No f
Employment Status: Employed Retired ZI Homemaker ID Other ID
NOTE: IF APPOINTED,YOU WILL BE REQUIRED TO FOLLOW CERTAIN LAWS THAT 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).
• 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,
EMP OYEES A GENCY MEMBERS."
1213 /oZ J(',_[ie, S 401
A I' ant's Signatu Date Name of Applicant(PLEASE PRINT)
Received in the City Clerk's Office by:
Name of Deputy Clerk Control No. Date
M I A M I•DADE
SOURCE OF INCOME STATEMENT
Please Print or Type First Name Middle Name Initial Last Name
Disclosure
For Tax Year
Name: S Ending:
Mailing Address: y �C%�r 14V6 4'� Q
City/State/Zip: 33139//
Social Security Number: C am— 26 63 V
Filing as a: ® County Employee:
® Municipal Employee of:
Position held or sought:
0-0� iA61 - (Jdr xke4q
Board where serving: Term or Employment
Began on: lalqllA
Department where employed:
Work Address: 42
If your home address is exempt from public records pursuant ton�, �/y X��!
Florida Statutes§119.07 please check here(read instructions): ® Work Telephone: (J
Home Address: CP°a:� 4'CA; '!! o Y
treet Address
3t,?
City State Zip Code
Please list below in descending rder with the largest source first, the name, address and
9 9
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
I hereby swear(or affirm)that the aforesaid information is a true and correct statement.
Sh6nature of pe on disclosing Date Aignbd
:M i
City of Miami Beach
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miamibeachfl.gov
CITY CLERK'S OFFICE CityClerk @miamibeachfl.gov
Telephone: 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's Name: U tie,
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.
/a L-3 LldL
Si t re Date
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application.doc