Loading...
Jessica Burns 06/30/2015 /M IANNIBEACH 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 June 25, 2014 Jessica Burns r 222 South Coconut Lane Miami Beach, FL 33139 SUBJECT: Committee for Quality Education in MB Congratulations! You have been appointed as a Representative of the PTA for South Pointe Elementary to the above referenced agency, board or committee for a term ending, 06/3 0/2 015. If you are unable to accept this appointment, please notify the City Clerk's Office at (305) 673-7411 . Sincere4Eranado dfael City Clerk cc: Saul Frances, Parking Director Dr. 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 2-11 .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 Employees We are committed to providing excellent public service and-safety to all 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.miamibeachfl.Qov OFFICE OF THE CITY CLERK,Rafael Granado,City Clerk Tel:(305)673-7411,Fax:(305)673-7254 TO: Jessica Burns RE: Committee for Quality Education in MB 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: 06/30/2015. I 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 Ofcersandunderstand 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. Je sica Burns Sworn to and subscribed before me thiscAr day of '5� , 2014 Silvia Prieto Deputy Clerk *Please visit the City of Miami Beach website at www.miamibeachfi.gov under City Clerk/Board and Committees for additional information regarding the Financial Disclosure Requirements. We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical,historic community. ` �01AMI --� BOARD AND COMMITTEE APPLICATION FORM Last Name-- - -- -- - - - --- - - _First Name- - -- - - _Middle Initial- - F7L n t,,t� L o_4i e. 3, C tY)/aim i 3,e� 3 13 c� Home Address City State Zip Code 28 (7/ 9 ) d1o, 65� 9 9 Ve-r-I Zoe-,. Home Telephone Work Telephone_ Cellular Telephone Email addres 1)/,Busi ess 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)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. S. • Resident of Miami Beach for a minimum of six(6) months: Yes or No • Demonstrates ownership/interest in a business in ' mi Beach for a minimum of six months: Yesor No ZI • Are ou registered voter in Miami Beach: Yes 4V or No Ca Y 9 • I am now a resident of: North Beach C3 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. 0 Ad Hoc Charter Review and Revision Board ❑Disability Access Committee 0 Miami Beach Human Rights Committee 0 Ad Hoc Committee Centennial Celebration ❑Gay, Lesbian,Bisexual and Transgender 0 Miami Beach Sister Cities Program Enhancement Committee(GLB 0 Affordable Housing Advisory Committee ❑Health Advisory Committee ❑Normandy Shores Local Government Neighborhood Improvement ❑Art in Public Places Committee 0 Health Facilities Authority Board 0 Parks and Recreation Facilities Board 0 Board of Adjustment* ❑Hispanic Affairs.Committee ❑Personnel Board ❑Budget Advisory Committee ❑Historic Preservation Board ❑.Plannin .Board . 0 C mmittee on the Homeless ❑Housing Authority 0 Police Citizens Relations Committee -Vtommittee for Quality Education in MB 0 Marine&Waterfront Protection Authority 0 Production Industry,Council ❑Convention Center Advisory Board, ❑Miami Beach Commission for Women ❑Sustainabilit Committee 0 Design Review Board* ❑Miami Beach Cultural Arts Council 0 Transportation,Parking,&Bicycle-Pedestrian Facilities-Committee 0 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 COMMITTEESW APPLICATION REVISED.docx `�/ °O Note: If applying for Youth Center Advisory Board, please indicate your affiliation with the Scott Rakow Youth Center: 1..-P-ast..8ervice-on-the-Youth._C.enter_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: Child's name: Age: Program: Child's name: Age: Program: • Have you ever been convicted of a felony?Yes. or No L.42 If yes,please explain in detail-- • Do you currently have a violation(s)of City of Miami Beach Code?Yes or Nolf yes, please explain in detail: • Do you currently owe the City of Miami Beach any money?Yes[D or No If yes,explain in detail:. •Are you currently serving on any City Board or Committee?Yes Ca or No LvQ1 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 ID or No 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 diversity reporting requirements. Gender: Male Ll Female Race/Ethnic Categories What is your race? African-American/Black Caucasian/White ��11,, I4,3 Asian or Pacific Islander 4�Native-American/American Indian Other—Print Race:. Page 2 of 4 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED.docx 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 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: o 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. Upon request,copies of these laws maybe 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." p i nt's n ure ate Name of Applicant(PLEASE PRINT) eceived in the City Clerk's Office by: 6e:-0j4;0 ' ; 36 Z? Name of Deputy Clerk Co trot 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 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED.docx MIAMI BEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach,Florida 33139, ww+v.miami�eachA.aov _ CITY CLERK Office CiiyClerk @miorniheachfl.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: l understcnd that no (after Than JULY 1 OF EACH YEAR.all members of Boards and Committees of the City of i 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, �,vhose sole or primary responsibility is to recommend legislation or give advice to the City Commission, must f le, even though you may have been recently appointed. You must file one of the follci,ving %P.-ith the City Cleric of {Miami Beach. 1700 Convention Center Drive. ,'�.�liami Beach Florida, by July 1, 2010. 1. A "Source of Incom-n Statement (at<achad) 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 pei son 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. nctur Dat--: