Harold Foster 12/31/2013Vj
® MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeochfl.aov
OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk
Tel: (305) 673-7411, Fax: (305) 673-7254
02/28/2012
Harold Foster
3100 Collins Ave #404
Miami Beach, Florida 33140
SUBJECT- Health Advisory Committee
Congratulations! You have been reappointed by the City Commission to the above
referenced agency, board or committee for a term ending: 1213112013.
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,
/k,� s�
Robert Parcher
City Clerk nn
C "
cc: Saul Frances, Parking Director
Cliftonf Leonard
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.
MIAMI CITY OF MIAMI BEACH
V I Fos.le � ��e r C� RD AND COMMITTEE APPLICATION FORM
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Home Address City StateZip J C5 roc-� 1.
Home Telephone (� Work,Telephone Cellular Telephone Email address
:b a`A S �� rC((_-I�� Position: 111 0 V10!1 l rw t�pL�`
Business Name
� o
Business Address City State lZip Code
Professional License(describe) Expires: r`
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 Eiry;
this requirement shall be fulfilled in the following ways: a. An individual shall have been a resident of the city for a-minim°um of�i�C
months; or b. An individual shall demonstrate ownership/interest for a minimum of six months in a business es tablishedWthe E43
for a minimum of six months.
• Resident of Miami Beach for a minimum of six (6) months:Yes ID or No `D
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six months:Yes or No
• Are you a registered voter in Miami Beach: Yes El or No ED
. I am now a resident of: North Beach I1 South Beach ID 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 bv the CitV 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 Gay, Lesbian, Bisexual and Transgender Parks and Recreation Facilities Board
Enhancement Committee GLB
Beautification Committee Golf Advisory Committee Personnel Board
Board of Adjustment' Health Advisory Committee Planning Board*
Budget Advisory Committee Health Facilities Authority Board Police Citizens Relations Committee
Capital Improvements Project Hispanic Affairs Committee Production Industry Council
Oversight Committee
Committee on the Homeless Historic Preservation Board Safety Committee
Committee for Quality Education in MB Housing Authority Single Family Residential Review Panel
Community Development Advisory Loan Review Committee Sustainabilit Committee
Community Relations Board Marine Authority 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
Design Review Board** Miami Beach Human Rights Committee Youth Center Advisory Board
Disability Access Committee Miami Beach Sister Cities Program Waterfront Protection Committee
Board Required to File State Disclosure Form
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
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/I
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 U Years of Service:
2. Present participation in Youth Center activities by your children Yes U No E—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:
•Have you ever been convicted of a felony:Yes C=3 or No If yes,please explain in detail:
• Do you-currently have a violation(s)of City of Miami Beach codes: Yes 0 or No[:J If yes,please explain in detail:
• Do you currently owe the City of Miami Beach any money:Yes U or No If yes, explain in detail
•Are you currently serving on any City Boards or Committees: Yes 09 or No U. If yes;which board?
•What organizations in the City of Miami Beach do you currently hold mejnbership in?
�Y1,13 lip I fit, vsea•.. l��
Name 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 ID or No ID.Which department?
• Pursuant to City Code Section 2-25(b): Do you have a parent U,spouse Z1, child[=a brother U,or sister L3 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.
Vne gin:Ch k on e only(1)
Male Female(D
(Not of Hispanic Origin):All persons having origins in any of the original peoples of Europe, North Africa or the Middle East.
uAfrican-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,or
the Pacific Islands. This area includes,for ex mple,China,India,Japan,Korea,the Philippine Islands and Somoa.
LaAmerican Indian or Alaskan Native: persons having origins in any of the original peoples of North America,and who maintain
Cultural identification throw h tribal iation or community recognition.
Physically Challenged: Yes or o
Employment Status: Employed Retired U Homemaker 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.
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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 I 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."
%--ogw 4CArdi LIQJ- der
Applicant's Signature Date Name of Applicant(PLEASE PRINT)
Received in the City Clerk's Office by : ZZ
Name of Deput Jerk Control No. 7 vbafe
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