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Sharon Douglas 12/31/2013 I\A 11 A V�I B 7EA C H 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)673-7,411, Fax: (305)673-7254 Email CityClerk @miamibeach.gov 07-16-2013 Sharon Dodge 1680 Meridian Ave. Ste., 101 Miami Beach, Florida 33138 S#UBJECTK Bicycle-Pedestrian Facilities Advisory Committee Congratulations! You have been appointed by Commissioner Michael Go'ngora 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 Jose Gonzalez 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 Employee 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 Sharon Dodge RE: Bicycle-Pedestrian Facilities 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: 12/31/2013. 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 whic L have served. Sh ron Dodge Sworn to and subscribed before me this day of , 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. MIAMIBOARD AND COMMITTEE APPLICATION FORM Last Name First Name Middle Initial -� Home Address City State Zip Code Home Telephone ork elephone Cellular Telephone Email address Business Name t Occupation Beez C4?71 Business Address Ulty State Zi Code 3 Professional License(describe): i G�- � -° Expires: �� Please attach a copy of curren effective professional license. Pursuant to City Code section 2-22(4)a & 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 mont 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 • Demonstrates owners hi /interest in a business in Miami Beach or a minimum of six months: Yes O or No ID P • Are you a registered voter in Miami Beach: Yes 0 or No - • I am now a resident of: North Beach 0 South Beach Middle Beach • I am applying for an appointment because I have special abilities, knowI dge and experience. Please list below: hL e 7- k., rk ---r . t • Are you presently a registered lobbyist with the City of Miami Beach?Yes ID 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. ❑Affordable Housing Advisory Committee ❑Fine Arts Board ❑ Normandy Shores Local Government Neighborhood Improvement Art in Public Places Committee ❑ Disability Access Committee ❑ Parks and Recreation Facilities Board ❑Beautification Committee ❑Gay, Lesbian, Bisexual and Transgender ❑ Personnel Board Enhancement Committee GLBT Bic cle-Pedestrian Advisory Committee ❑Golf Advisory Committee ❑ Planning Board ❑ Board of Adjustment* ❑ Health Advisory Committee ❑ Police Citizens Relations Committee ❑ Budget Advisory Committee ❑ Health Facilities Authority Board ❑ Production Industry Council ❑Capital Improvements Projects ❑ Hispanic Affairs Committee ❑Safety Committee Oversight Committee ❑Committee on the Homeless ❑ Historic Preservation Board ❑Single Family Residential Review Panel ❑Committee for Quality Education in MB ❑ Housing Authority ❑Sustainability Committee ❑Community Development Advisory ❑Loan Review Committee ❑Tennis Advisory Committee ❑Community Relations Board ❑ Marine Authority ❑Transportation and Parking Committee ❑Convention Center Advisory Board W4iami Beach Commission for Women ❑Visitor and Convention Authority ❑ Debarment Committee ❑ Miami Beach Cultural Arts Council ❑Youth Center Advisory Board °O ❑ Design Review Board** 0 Miami Beach Human Rights Committee ❑Waterfront Protection Committee ❑ Miami Beach Sister Cities Program Page 1 of 4 r °O Note: If applying for Youth Center Advisory Board, please indicate your affiliation with the Scott Rakow Youth Center: 1. Past service on the Youth Center Advisory Board:Yes U No Dates of Service: 2. Present participation in Youth Center activities by your children:Yes U No If yes, please list below the names of your children,their ages and the programs in which they participate: Child's name: Age: Program: Child's name: Age: Program: • Have you ever been convicted of a felony?Yes 0 or No U If yes, please explain in detail: • Do you currently have a violation(s)of City of Miami Beach Code?Yes ID or N 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 Board or Committee?Yes or No If yes,which board/committee? • In what organization(s)in the City of Miami Beach do you currently hold membership?, Name Position Name Position • List all properties owned or in which you have an interest within the City of Miami Beach: •Are you now employed by the City of Miami Beach?Yes U or No Which department and title? • Pursuant to City Code Section 2-25 (b): Do you have a parent U, spouse U, child U brother La or sister U who is employed by the City of Miami Beach?Check all that apply. If"Yes," identify person(s)and 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 City diversity reporting requirements. Gender: Male L..J Female Race/Ethnic Categories What is your race? � African-American/Black 4 Caucasian/White Asian or Pacific Islander Native-American/American Indian Other—Print Race: Page 2 of 4 Do you consider yourself to be Spanish, Hispanic or Latino/a?Mark the "No"box if not Spanish, Hispanic, Latino/a. �No ZI Yes Do you consider yourself Physically Disabled? 4;.- No Yes 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: • 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). • Prohibition from lobbying before the 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). • Sunshine Law - Florida's Government-in-the-Sunshine Law was enacted in 1967. Today, the Sunshine Law regarding open government can be found in Chapter 286 of the Florida Statutes. These statutes establish a basic right of access to most meetings of boards,commissions and other governing bodies of state and local governmental agencies or authorities. • Voting conflict—Form 8B is for use by any person serving at the county, city or other local level of government on an appointed or elected board, council, commission, authority or committee. It applies equally to members of advisory and non-advisory bodies who are presented with a voting conflict of interest under Section 112.3143, Florida Statutes. 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 MIAMI BEACH CITY CODE, ENTITLED "STANDARDS OF CONDUCT FOR CITY OFFICERS, EMPLOYEES AND AGENCY MEMBERS AND ALL OTHER APPLICABLE COUNTY AND/OR STATE LAWS AND STATUTES ACCORDINGLY." Ap can ignat Da-(e Name of Applicant(PLEASE PRINT) r ` 71Received in the City Clerk's Office by: 3g, Name of Deputy Clerk Control No. Date PLEASE REMEMBER TO ATTACH A CURRENT RESUME, PHOTOGRAPH AND A COPY OF ANY APPLICABLE PROFESSIONAL LICENSE. ATTACH ADDITIONAL SHEETS, IF NECESSARY, TO PROVIDE REQUIRED INFORMATION. Page 3 of 4 _ _ __ _ _ a � _ __ _ ��. _ ._ . _ b . _� .� � � . . . _ _ _ _ �� '. '` � �.�����.` � a _ -,. ��. - ._• .. _.. _ �°c Kam'_ �-�",'..�_ � .. .. J�.. .� �.-,. �'�r ��r ref. ��, ��^ i -- ._.. r' ,.F'- ,. �( ._ �r f E s r i' _ .,. � I IfI E - I i __._ _ _ _.__..._._...._._....1 MIAMI BEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach,Florida 33139, www.miamibeachfl.gov CITY CLERK Office CityClerk @miamibeachfl.gov Tel:305.673.741 1 ,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: 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 complywith Miami-Dade County Disclosure Requirements. This meansthatthe 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, 2010. 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. Signature: D te: