Dona Zemo 12/31/2014 I AIVdBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139,www.miamibeachfl.gov
OFFICE OF THE CITY CLERK, Rafael Granado, City Clerk
Tel: (305)673-7411, Fax: (305)673-7254
Email CityClerk @miamibeach.gov
3/7/2013
Dona Zemo
3101 Indian Creek Dr Apt. 104
Miami Beach, Florida 33140
SUBJECTr y Community Development Advisory Committee
Congratulations! You have been reappointed by Mayor Matti Herrera Bower
to the above referenced agency, board or committee for a term ending: 12/31/2014.
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,
R ae4E. r ad o
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.
MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov
OFFICE OF THE CITY CLERK, Rafael Granado,City Clerk
Tel: (305)673-7411, Fax: (305)673-7254
Email CityClerk @miamibeach.gov
TO Dona Zemo
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: 12/31/2014.
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 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 Florid_a A(de ending on the board or committee on which I serve)on
July 1, following the closing of the cale ar year which I served.
r
Dona Zemo , (�
Sworn to and subscribed before me this!Z da y ,of GG� i"L '2013
Silvia 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.
CITY OF HI ANll BEACH
M iM BOARD AND COMMITTEE AP�PLIC.�TIO�m FO
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La Name�- r Q�h, 1 d4st Name n _ (1 Middle ki to
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Himddr��.� '"��S �6 CjtY _ State Zip Code ° (1
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Home Telephone Work Telephone Cellular Telephone Emai address
Position:
Busin f\ss Name
Business 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 demonstrate 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 or No
• Demonstrate an ownership/interest in a Busin ss in iami Beach for a minimum of six months: Yes ID or No
• Are you a registered voter in Miami Beach: Yes or
• I am now a resident of: North Beach South Beac 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 L.Jor 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 bV the City Clerk's Office. (Regular Boards of City)
❑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 GLBT
Beautification Committee ❑Golf Advisory Committee ❑ Personnel Board
❑Board of Adjustment* * 7— Health Advisory Committee F] Planning Board**
Budget Advisory Committee i Health Facilities Authority Board ❑ Police Citizens Relations Committee
D Capital Improvements Projects ❑ Hispanic Affairs Committee I n_ Production Industry Council
Oversight Committee
❑Committee on the Homeless 5 storic Preservation Board 1Z ❑Safety Committee
Committee for Quality Education in MB ❑ Housing Authority �!Single Family Residential Review Panel
1 ommunity Development Advisory n Loan Review Committee ❑Sustainabili Committee
N'C�iCommunity Relations Board ❑ Marine Authority ❑Tennis.Advisory Committee
Convention Center Advisory Board n Miami Beach Commission for Women ( ❑Transportation and Parking Committee
❑ Debarment Committee ❑ Miami Beach Cultural Arts Council isitor and Convention Authority
i--1 Design Review Board* E] Miami Beach Human Rights Committee ❑Youth Center Advisory Board
Disabili Access Committee ❑ Miami Beach Sister Cities Program ❑Waterfront Protection Committee
* Board Required to File State Disclosure Form
5 If you seek appointment to a professional seat(e.g., lawyer, architect)on the Board of Adjustment, Design Review Board,
Historic Preservation Board,or Planning Board, attach a copy of your currently-effectively license, and furnish the
following information:
Type of Professional License License Number ,
License Issuance Date , and License Expiration Date
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application NEWLY REVISED NEW LANGUAGE.doc
1
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4
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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 LA Years of Service:
2. Present participation in Youth Center activities by your children Yes ID No 0. 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:
•Have you ever been convicted of a felony:Yes ID or N f yes, please explain in detail:
• Do you currently have a violation(s)of City of Miami Beach codes:Yes or No s, please explain in detail:
• Do you currently owe the City of Miami Beach any money:Yes 0 or N If yes, explain in detail
•Are you currently serving on any City Boards or Committees:Ye or No ID. If yes;which board?
•What organizations in the City of Miami Beach do you currently hold membership in?
tJ�
Name Title
Name Title
List all properties owned or have an interest in,which are located within the City of Miami Beach:
• 1 am now employed by the City of Miami Beach:Yes 1—:1 or No ich department?
• Pursuant to City Code Section 2-25(b): Do you have a parent 0, 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.
Ethnic Origin: Check one onl 1
Gender: Male ED Female
hite (Not of Hispanic Origin):All persons having origins in any of the original peoples of Europe,North Africa or the Middle East.
IZI African-American/Black (Not of Hispanic Origin):All persons having origins in any of the Black racial groups of Africa.
ID 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,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 through triba ffilia on or community recognition.
Physically Challenged: Yes or N
Employment Status: Employed Retired�K Homemaker[D Other
Please remember to attach a current resume and a copy of any applicable
professional license.
Attach additional sheets, if necessary, to provide required information.
F:\CLER\SALL\aFORMS\BOARD AND COMMITTEES\BC Application NEWLY REVISED NEW LANGUAGE.doc
NOTE: IF APPOINTED, YOU WILL BE REQUIRED TO FOLLOW CERTAIN LAWS THAT APPLY TO CITY BOARDICOMMITTEE
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).
• 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 I HAVE RECEIVED, READ AND
WILL ABIDE BY CHAPTER 2, ARTICLE VII — OF THE CITY CODE "STANDARDS OF CONDUCT FOR CITY OFFICERS,
OYEES AND AGENCY MEMBERS." 'Dona Zp--jm o
I' Signature Date Name of Applicant(PLEASE PRINT)
z
Received in the City Clerk's Office by 3j�
ame of Deputy Clerk ntrol No. Date
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application NEWLY REVISED NEW LANGUAGE.doc
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: l��'C � Ending: _
Mailing Address: 3101 c C ', • l Oq
City/State/Zip:
Filing as a: ® County Employee:
® Municipal Employee of:
Position held or sought:
Board where serving: Term or Employment ?
Began on: .7
g r
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): ® 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: Ej
Description of;the Principal'
Natpe of Source of Income Address Business Activity
I hereby swear(or affirm)that the aforesaid information is a true and correct statement.
12 �3
Si re of person disclosing Date sig ed