Christy Farhat 06/30/2013 IM I A.,'vl I BEACH
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miomibeochfl.aov
OFFICE OF THE CITY CLERK, Rafael Granada, City Clerk
Tel: (305)673-7411, Fax: (305) 673-7254
Email CityClerk @miamibeach.gov
March 19, 2013
Christy Farhat
SUBJECT: Committee For Quality Education In Miami Beach
Congratulations! You have been appointed as a Representative of the PTA for
South Pointe Elementary School to the above Agency, board or committee for a
term ending 06/30/2013.
If you are unable to accept this appointment, please notify the City Clerk's Office
at (305) 673-7411 .
Sincerely,
Ra ael E. Granado
City Clerk
cc: Leslie Rosenfeld, Liaison
Saul Frances, Parking Director
We are committed to providing excellent public service and safety to oil 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.miamibeacElL9ov
OFFICE OF THE CITY CLERK, Rafael Granada,City Clerk
Tel: (305)673-7411, Fax: (305)673-7254
Email CityClerk @miamibeach.gov
TO Christy Farhat
RE: Committee for Quality Education in MB
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: 6/30/2013.
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 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 hi I have served.
Christy Farhat
Sworn to and subscribed before me this da of 913.
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.
s
� CITY OF P1AP1 BEACH
BOARD AND COMIN11TTEE APPLICATION FORM
dbril
Last Name / f z First a �rn' Mi le Initial A'q
yo-rpe Add r ss_(e1 O-73 City State Zip Code
Home Telephone JJ ,Work Telephone Cellular Telephone Email address
Position:
Business 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 16 or No
. Demonstrate an ownership/interest in a business iin{Miami Beach for a minimum of six months: Yes Zor No ED
• Are you a registered voter in Miami Beach: Yes� or No
• I am now a resident of: North Beach Z1 South Beach Middle Beach
• I m applying for an appointment because I have special abilities, knowledge and experience. Please list below:
�T�I
e 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)
D Affordable Housing Advisory Committee D Fine Arts Board D Normandy Shores Local Government
Neighborhood Improvement
D Art in Public Places Committee it Gay, Lesbian, Bisexual and Transgender ❑ Parks and Recreation Facilities Board
Enhancement Committee GLBT
D Beautification Committee D Golf Advisory Committee ❑ Personnel Board
D Board of Adjustment* * I �D Health Advisory Committee Ci Planning Board**
Budget Advisory Committee ❑ Health Facilities Authority Board ❑ Police Citizens Relations Committee
D Capital Improvements Projects ❑ Hispanic Affairs Committee ❑ Production Industry Council
Oversight Committee
❑Committee on the Homeless D Historic Preservation Board i Safety Committee
❑Committee for Quality Education in MB ❑ Housing Authority Single Family Residential Review Panel
u Communi Development Advisory ❑ Loan Review Committee ❑Sustainability Committee
D Community Relations Board ❑ Marine Authority ❑Tennis Advisory Committee
D Convention Center Adviso Board Miami Beach Commission for Women 70 Transportation and Parkin Committee
D Debarment Committee Miami Beach Cultural Arts Council Ivisitor and Convention Authority
i 1 Design Review Board'`T ❑ Miami Beach Human Rights Committee 'outh Center Advisory Board
Disability Access Committee D 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
F:\CLER\$ALL\aFORMS\BOARD AND COiMMITTEES\BC Application NEWLY REVISED NEW LANGUAGE.doc
Note: If applying for Y uth SOR Bard, please i�d'cate your affiliat'on with the Scott Rakow Yout nter:
1t2kwj- 112 V1
1. Past service on the Youth Center Advisory Board:Yes U No VJ Years of Service:
2. Present participation in Youth Center activities by your children Yes U No U 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:
eHave you ever been convicted of a felony:Yes ID or No Z If yes, please explain in detail:
• Do you currently have a violation(s)of City of Miami Beach codes:Yes�j or No . If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money:Yes I—D or No�6 If yes, explain in detail
•Are you currently serving on any City Boards or Committees:Yes Z)or No[A. If yes;which board?
•What organizations in the City of Miami Beach do you urrently hold embership in?
& � Mew T
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 U or No .Which department?
• Pursuant to City Code Section 2-25(b): Do you have a parent U, spouse El, child ZI 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)
Ver: Male ID Female
White (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.
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 throu h tribal affiliation or community recognition.
Physically Challenged: Yes or No E
Employment Status: Employed E--:) Retired ID Homemaker ef 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:ICLERISALL1aFORl\)ISIBOARD AND CONIMITTEESIBC Application NEWLY REVISED NEW LANGUAGE.doc
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."
41-4113 &'OK
Applicant's Signature ba Name of Applican (PLEASE PRINT)
Received in the City Clerk's Office by
Name of Deputy Clerk Control No. Date
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application NEWLY REVISED NEW LANGUAGE.doc
MIAMI BEACH
city of Miami Beach,
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www miamibeochfLoov
CITY CLERK Office CityClerk @miamibeachfl.gov
Tel: 305.673.7-411 , 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 j(i) ".(2)
Board Member
name:
I understand that no :later-than July 1, of each year oil 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 fiile,:eventhough 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 f ne not-to exceed
.$500.00 or by imprisonment in the county,}ail for period not to exceed sixty
days, or both:
W3
Signature: Date_:
M I A M 1•DADE
® SOURCE OF INCOME STATEMENT
Please Print or Type First Name Middle Name/Initial Last Name
Disclosure
For Tax Year
Rrs�� Je Ending:
Name: L
Mailing Address: 53S
City/State/Zip:
Filing as a: ® County Employee:
® Municipal Employee of:
Position held or sought:
Board where serving:
&,c Term or Employment
[, Began on: 3 /; /3
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: / �l7
Street Address
&th F,,- , 313
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:
Description of the Principal
Name 015ource of Income Address Business Activi
KeV
I hereby swear (or affirm) that the aforesaid information is a true and correct statement.
i
1
Signa a of person disclosing at signed