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Christy Farhat 06/30/2014 Rep for So Pointe Elementary M I N\11,I BEACH 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 June 14, 2013 Christy Farhat 6538 Collins Ave. #402 Miami Beach, FL 33141 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 06/30/2014. If you are unable to accept this appointment, please notify the City Clerk's Office at (305) 673-7411 . Sincerely, Ra el E. Granado City Clerk cc: Leslie Rosenfeld, Liaison Saul Frances, Parking Director 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 Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfi.gov 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 Miami Beach 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: 6/30/2014. 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 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. Christy Farhat Sworn to and subscribed before me this�2_day o , 201 e -► L 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. I M OF MIAMI BEACH BOARD AND CC)MN11 T TEE APPLICATION FORM L FdJ,e­1940� C 'Y,�S. Last Name ® � �� First�l�m��+ �� Mi le Initial 657 o e Add NUOS49 City J[ State Zip Code Home Telephone 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 in 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 South Beach&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 by 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 L Gay, Lesbian, Bisexual and Transgender I C! Parks and Recreation Facilities Board Enhancement Committee GLBT Beautification Committee ❑ Golf Advisory Committee ❑Personnel Board ❑Board of Adjustment* * ❑ Health Advisory Committee i Planning Board`* ❑Budget Advisory Commiee ❑ Health Facilities Authority Board ❑ Police Citizens Relations Committee Ei Capital Improvements Projects ❑ Hispanic Affairs Committee ❑ Production Industry Council Oversight Committee ❑Committee on the Homeless ❑ Historic Preservation Board Safety Committee n Committee for Quality Education in MB ❑ Housing Authority ±Single Family Residential Review Panel Community Development Advisory n Loan Review Committee ❑Sustainabili 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 1visitor and Convention Authority ❑ Design Review Board** ❑ Miami Beach Human Rights Committee Zouth 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 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application NEWLY REVISED NEW LANGUAGE.doc J. Note: If applyi g for Y uth dviso P B ard, please ind'cate your at'on with the Scott Rakow Youth enter: 1. Past service on the Youth Center Advisory Board:Yes No VJ Years of Service: 2. Present participation in Youth Center activities by your children Yes I.J No 12r 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 No Z If yes, please explain in detail: • Do you currently have a violation(s)of City of Miami Beach codes:Yes or No . 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 U or No . If yes;which board? •What organizations in the City of Miami Beach do you urrently hold embership in? -esi r 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 ED or No .Which department? • Pursuant to City Code Section 2-25(b): Do you have a parent U. spouse ED, child 0 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 only 1) G eer: Male U Female LO White (Not of Hispanic Origin):All persons having origins in any of the original peoples of Europe,North Africa or the Middle East. EZ]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 throu h tribal affiliation or community recognition. Physically Challenged: Yes or No Employment Status: Employed Retired E-D 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. F:\CLER\$ALL\aF-ORINIS\BOARD AND CONIMITTEES\BC 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." 0_ Applicant's Signature ba Name of Applican (PLEASE PRINT) 43 0 Received in the City Clerk's Office by vi 2:�� Name of Deputy Clerk Control No. /Date F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application NEWLY REVISED NEW LANGLIAGE.doc � I M" °ADE SOURCE OF INCOME STATEMENT a Disclosure for Tax Year Ending Last Name First Name Middle Name/Initial a Wiling Address—Street Number,Street Name,or P.O.Box City,State,Zip ID Number If your home address is your mailing address,and your home address is exempt from public records pursuant to Fla.Stat.§119.07,read instructions on the following page and check here.❑ Filing as an Employee ❑County Employee ❑Municipal Employee, Name of Municipality: Position held or sought Department where employed Work address Work telephone Term began on Filing as a Board Member v - ❑ County Board Member Municipal Board Member, Name of Municipality: Board where serving Work address Work telephone Term began on List below every source of income you received,along with the address and the principal activity of each source. Include your public salary.Place the sources of income in descending order,with the largest source first.Also, include any source of income received by another person for your benefit. However,the income of your spouse or any business partner need not be disclosed. If continued on a separate sheet,check here.❑ Name of Source of Income Address Description of the Principal Business Activity S+&u wL hzme-., Mom 34 deq 4 1 o imm AL I hereby swear(or affirm)that the information above is a true and correct statement. RECEIVED BY ELECTIONS DEPARTMENT: ❑ Hardcopy ❑ Electronic Copy Signature of person disclosing Print name ;ate hned OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/Initials: Scanned Date/Initials: 138 SP-14 2/13