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Rosa M. Neely, Treasure Isl PTA Rep - 6/30/2014 City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139,www.miomlbeachfi.gov OFFICE OF THE CITY CLERK, Rafael Granado,City Clerk Tel: (305)673-7411, Fax: (305)673-7254 July 24, 2013 Rosa M. Neely SUBJECT: Committee for Quality Education in Miami Beach Congratulations! You have been appointed as a Representative of the PTA for Treasure Island Elementary to the above referenced 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, ere'y Ra ael E. Sincerely, City Clerk cc: Saul Frances, Parking Director Leslie Rosenfeld, Liaison 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 2-1 1 .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. 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 TO: Rosa Neely RE: Committee for Quality Education in Miami Beach 1 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 have been appointed for a term ending: 06/30/2014. 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 Amendment and Code of Ethics for Public Offl'cers andunderstand 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 the State of Florida (depending on the board or committee on which I serve) on July 1 st, following the closing of the calendar year on which I have served. Rosa N y- Sworn to and subscribed before me this day of A/P/1 , 2014 a Silvia Prieto Deputy Clerk *Please visit the City of Miami Beach website at www.miamibeachfl.gov under City Clerk/Board and Committees for additional information regarding the Financial Disclosure Requirements. We are �nmitted to.�r�yidin� cellent Pu�lic��ervice and�af�ty#o al�w olive wgrk ar�d flay in our,vibrapt+tr��i�a��s�g��.��nmunity. e are corrm,,.= .o prc , ,nq excel.en,pv ,c serv,ce an scr ery' o a w,o hve,tvorc,arr p y ,r,our vrJran7, ,,op,c s b r y. s w MIAMI BEACH /0!5"t4- - A/ I BOARD AND COMMITTEE APPLICATION FORM Last Name First Name, Middle Initial 7 Ave�9& �J- PD Home Address City V State Zip Code 3C>�-C)Xq-(�ya3 pS-431-C1�3 r�2e� �eM� 'o�c1L, Home Telephone Work Telephone Cellular Telephone Ema' ddress Unlu . o-P M I OL IM / 6 �� rp /y , Business Name Occupation 0 auyi.-a-P Ga� F C_ -3S t4 SCLVJ Business Address City State Zip dode Professional License(describe): Expires: Please attach a copy of currently 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 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 or No 4� • Demonstrates ownership/interest in a business in Miami Beach for a minimum of six months: Yes 1:3 or No Zjr •Are you a registered voter in Miami Beach: Yes�J or No 4� • I am now a resident of: North Beach�D South Beach Middle Beach IZI • 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 1:3 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 ❑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 Author' Board ❑Parks and Recreation Facilities Board ❑Board of Adjustment* 0 Hispanic Affairs Committee ❑Personnel Board D Budget Advisory Committee ❑Historic Preservation Board ❑Planning Board ❑Committee on the Homeless ❑Housing Authority 0 Police Citizens Relations Committee ❑Committee for_Qualit _Education in MB ❑-Marine-&Waterfront.P-_rotection Authorit -------------0 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 * Board members are required to file Form 1 —"Statement of Financial Interest"with the State. {If you seek appointment to a professional seat (e.g., lawyer, architect, etc.) 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 License Expiration Date Page 1 of 4 F:ICLERI$ALL1aFORMSIBOARD AND COMMITTEESIBC APPLICATION REVISED.docx T f A °O Note: If applying for Youth Center Advisory Board, please indicate you iation with the Scott Rakow Youth Center: 1. Past service on the Youth Center Advisory Board:Yes No Dates of Service: 2. Present participation in Youth Center activities by your children:Yes� No If yes, please list below the names of your children,their ages and the programs in which they participate:J! 1 Child's name: :Yws4i h1 Age: 1 Program: Child's name: Age: Program: • Have you ever been convicted of a felony?Yes or N If yes,please explain in detail:- • Do you currently have a violation(s)of City of Miami Beach Code?Yes U or N If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money?Yes C]or No qhj If yes,explain in detail:. •Are you currently serving on any City Board or Committee?Yes or No If yes,which board/committee? 1 • 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 ID or N Which department and title? • Pursuant to City Code Section 2-25 (b): 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): 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-diversi tY re ortin g req uirementsF. - _- - - -- Gender: Male Female Race/Ethnic Categories What is your race? African-American/Black Caucasian/White ID Asian or Pacific Islander ID Native-American/American Indian ED Other—Print Race: Page 2 of 4 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED.docx � 1 Do you consider yourself to be Spanish, Hispanic or Latino/a?Mark the"No"box if not Spanish, Hispanic, Latino/a. No Yes Do you consider yourself Physically Disabled? No ID 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). • 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 813 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 S, EMPLOYEES AND AGENCY MEMBERS AND ALL OTHER APPLICABLE COUNTY AND/OR STATE LAWS AND ST LITE CORDINGLY." Applicant's Signature Date Name of Applicant(PLEASE PRINT) Received in the City Clerk's Office by: J Name of Deputy Jerk Control No. bate 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 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED.docx Nook MIAMI-Nib-EN SOURCE OF INCOME STATEMENT Disclosure for Tax Year Ending Las2K�Ezx First Name Middle Name/Initial ,2 ��✓ Ma iling Address—Street Number,Street Name,or P.O.tox 9b I 9D 14 City,State,Zip ID Number N • 6 o i (1 PL 3 3 14( 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 ] Municipal Board Member, Name of Municipality: Board where serving , Work address J Work telephone Term began on coaC-c S'�-, f�ve . �c�v.�� `��s�c)g 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 aco I hereby swear(or affirms that the information above is a true and correct statement. RECEIVED BY ELECTIONS DEPARTMENT. . ❑Hardcopy ❑ Electronic Copy Signature,/of person disclosing rve Printname Date signed OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date!lnitials: Scanned Date/Initials: 138 SP-14 2/13 MIAMI- 'DE SOURCE OF INCOME STATEMENT Disclosure for Tax Year Ending Last Name First Name Middle Name/Initial Mailing Address—Street Number,Street Name,or P.q.Box "I cl D t 14 s c?Ino 144 rive -_fl-_c01--4 City,State,Zip ID Number 0 vk�� '�P_ 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.F] 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 Municipal Board Member, Name of Municipality: I"r I C) Board where serving Q�Q�i �c�i its a'f r•D�J �C�YwI�`t�r 'I�'E' Work address Work telephone Term bega on C&azo �� 3os- <<-��a 3 0 / 3 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 �m U n Cow S Ne. I hereby svvelar(or affirms that the information above is.a true and correct.statement. RECEIVED BY ELECTIONS DEPARTMENT: ❑Hardcopy ❑ Electronic Copy Sig ture of person disclosing Print name Date signed OFFICE USE ONLY Accepted: Y / N Deficiency: °racessed Date!Initia!s: Scanned Doi,'IniSals: 138_SP-1' 2/13- MIAMI City of Miami Beach, 1700 Convention Center Drive, Miami Beach,Florida 33139, WWW.miamibeachfl.aov 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 2-1 1.1(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 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 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. Sig oture: Date: