Harvey J. Burnstein application package AMI BEACH
Last Name Fir t Name Middle Initial
,.r
Home Address City J State Zip Code
Home Telephone Work Telephone Cellular Telephone Email address •1��°
Business Name Occupation
Business Address city. State Zip Code
Professional License(describe): Expires:
Please attach a copy of currently effective professional license.
Pursuant to City Code section 2-22(4)aaMembers 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: Yesor No
• Demonstrates 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: Yea or No
• I am now a resident of: North Beach South Beach Middle Beach a
• I am applying for an appointment because I have special abilities, knowledge and experience. Please liif-below:
• Are you presently a registered lobbyist with the City of Miami Beach?Yes or No C:",
= I
Please list your preferences in order of ranking [1] first choice [2] second Choice, and [3] third choice:,PIi�$e note that
only three(3) choices will be observed by the City Clerk's Office.
❑Ad Hoc Charter Review and Revision Board ❑Disability Access Committee ❑Miami Beach Human Rights Committee
❑Ad Hoc Committee Centennial Celebration ❑Gay, Lesbian,Bisexual and Transgender ;Miami Beach Sister Cities Program
Enhancement Committee(GLBT
❑Affordable Housing Advisory Committee ❑Health Advisory Committee ❑Normandy Shores Local Government
Neighborhood Improvement
❑Art in Public Places Committee ❑Health Facilities Authority Board ❑Parks and Recreation Facilities Board
❑Board of Adjustment* * ❑Hispanic Affairs Committee ❑Personnel Board
❑Budget Advisory Committee ❑Historic Preservation Board ❑Planning Board
❑Committee on the Homeless ❑Housing Authority ❑Police Citizens Relations Committee
❑Committee for Quality Education in MB ❑Marine&Waterfront Protection Authority ❑Production Industry Council
❑Convention Center Advisory Board ❑Miami Beach Commission for Women ❑Sustainability Committee
❑Design Review Board* ❑Miami Beach Cultural Arts Council ❑Transportation,Parking,&Bicycle-Pedestrian
Facilities Committee
❑Visitor and Convention Authority
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°O 16If.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 No r Dates of Service:
2. Present participation in Youth Center activities by your children:Yes F.3 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? or` If yes, please explain in detail:
• Do you currently have a violation(s)of City of Miami Beach Code?1l��or if yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money? on If yes,explain in detail:
•Are you currently serving on any City Board or Committee? or&f 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 CittAof Miami Beach:
•Are you now employed by the City of Miami Beach?)[D or66
Which department and title?
• li b q QI b Z a Do you have a parent spouse child brother or sister who is
employed by the City of Miami Beach?Check all that apply.
If"Yes,"identify person(s)and department(s):
ilVla Femal
frican-American/Black
Caucasian/White
Asian or Pacific Islander
ID Native-American/American Indian
ID Other—Print Race:
dark the "No"box if not Spanish, Hispanic, Latino/a.
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F:\CLER\$ALL1aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED.docx
II No
III Yes
No
Yes
• 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 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.
low
erApplicaqACWgriature Date Name of Applicant(PLEASE PRINT)
-J1
Received in the City lerk's Office b : ��G/ Z,� 14C
y y
Nf e of Deput Clerk Control No. Da e
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.
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NAIAMI
City of Miami Beach
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miamibeachfl.gov
CITY CLERK'S OFFICE CityClerk @miamibeachfl.gov
Telephone: 305.673.7411 Fax: 305.673.7254
Acknowledgement of fines/suspension for Board/Committee Members for failure to comply with Miami-
Dade County Financial Disclosure Code Provision Code Section 2-11.1(i) (2)
Board Member's Name: 7�r"� 4-c
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 comply with Miami-Dade County
Financial 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 file, even
though they may have been recently appointed.
One of the following forms must be filed with the City Clerk of Miami Beach, 1700 Convention Center Drive,
Miami Beach, Florida, no later than .12:00 noon of July 1, of each year.
1. A "Source of Income Statement"
For your convenience, the form is attached. The form can also be downloaded at:
http://www.miamidade.gov/elections/Library/source of income statement.pdf
2. A "Statement of Financial Interests (Form 1)"
For your convenience, the form is attached. The form can also be downloaded at:
http://www.ethics.state.fl.us/ethics/forms.htmi
3. A Copy of your 2013 Federal Income Tax Return
Failure to file one of these forms, pursuant to the Miami-Dade County Code, may subject the person to a fine
of no more than $500, 60 days in jail or both.
Signa re Date
Updated:Wednesday,March 05,2014
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HARVEY J BURSTEIN BI®
Philanthropy has always been an important part of Harvey J. Burstein's life. Born and
raised in Chicago, Burstein was immersed in social and educational programs and when
he relocated to Miami a decade ago, his volunteerism-continued. Among his peers, he has
earned a reputation for being willing to roll up his sleeves and do whatever it takes to get
the job done. In recognition of his extraordinary leadership and dedication to the arts and
his involvement in the Jewish. community, The Center for the Advancement of Jewish
Education (CAJE) honors him with the 2009 Community Arts and Education Award
(CAEA). The presentation takes place Thursday.. January 22, 2009, at the opening
reception for the 12t" Miami Jewish Film Festival.
This prestigious award recognizes those who support both the arts and Jewish education
and who enrich the lives of all our residents through their dedication and activism.
Burstein join a distinguished list of Jewish community leaders to receive the CAJE Arts
and Education Award including: Nancy and Norman Lipoff, Rhoda Levitt, Nedra Oren,
Gloria and Howard Scharlin, Mitchell Kaplan, Irma Braman, Craig Robins, the Arison
Family, Myrna and Sheldon Palley and Raquel and Michael Scheck.
"Harvey Burstein is the ultimate community supporter," said Rhoda Levitt cultural arts
activist. " He g ives from the heart and crosses the board to many different kinds of
organizations. Harvey doesn't just write the check, lie is the most loyal supporter, attends
all of the meetings, and is truly a professional volunteer. He participates wholeheartedly,
doing things that are not asked of him. When the performing arts center was becoming a
reality, Harvey approached his circle of friends, and acting independently as a caring
member of the community, he organized a generous contribution to the center. "
In Chicago, Burstein participated on every level from a sponsor and producer at the
Victory Gardens the Baliwick Theatres to the Joffrey Ballet; serving as a board member
for the Jewish AIDS Network to getting behind the wheel and delivering meals for Open
.Hand Chicago.
Upon relocating to Miami a decade ago, Burstein lost no time in beginning a new chapter
in his service to the community. He has been involved with the CAJE Miami Jewish
Film Festival (MJJF) for 10 years and has served on the Festival's Advisory Committee.
"Harvey brings an extensive knowledge of the arts to our Committee along with a great
deal of energy. He is always there contributing to the success of our festival," said Ellen
Wedner Director of the MJFF.
He has been a board member, a sponsor and /or an advisor for the following
organizations: Art Center/South Florida and SAVE Dade; Ballet Ganionet Maximum
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- MIAMI BEACH, FL 33139-7547
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MIAMI-DMA-DE SOURCE OF INCOME STATEMENT
Disclosure or Tax Year Ending Last Name First Name Middle Name/Initial
1 V-J
Mailing Address—Street Number,Street Name,or .0.Box
1 s s U\ i-v\ a P,� J�.
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
❑ County Board Member �7g Municipal Board Member, Name of Municipality: l A Vv\
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
- N 14L i r<4�-4-. �—
I hereby swear(or affirm)that the information above is a true and correct statement. RECEIVED BY ELECTIONS DEPARTMENT:
❑ Hardcopy
❑ Electronic Copy
Si atuee of perso dis ing
� r
Print name Date signed
OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/Initials: Scanned Date/Initials:
138 SP-14 2/13