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Dale Stine 12/31/2018MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov OFFICE OF THE CITY CLERK, Rafael Granado, City Clerk Tek (305) 673-7411, Fax: (305) 673-7254 Email CityClerk@miamibeach.gov November 15, 2016 Mr. Dale Stine 1573 Pennsylvania Ave. #1N Miami Beach, Florida 33139 SUBJECT: LGBT Advisory Committee Congratulations! You have been reappointed by Commissioner Joy Malakoff to the above referenced, board or committee named above, fora term ending: 12/31/2018. Pursuant to City of Miami Beach Code Section 2-22 (5) a, "Notwithstanding any other provision of the City Code or of any resolution, commencing with terms beginning on or after January 1, 2007, the term of every board member who is directly appointed by a member of the City Commission shall automatically expire upon the latter of: December 31 of the year the appointing City Commissioner leaves office or upon the appointment/election of the successor City Commission member." If you are unable to accept this appointment, or have any questions, please call the Office of the City Clerk at 305.673.7411. Please read the enclosed materials carefully. Congratulations and good luck. Regards, Rafael nado City Clerk cc: Saul Frances, Parking Director Morgan Goldberg, City 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, 2-458 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 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 Email CityClerk@miamibeach.gov TO: Mr. Dale Stine RE: LGBT 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: 12/31/2018. 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 Florida Commission on Ethics Guide to the Sunshine Amendment and Code of Ethics for Public Officers 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 the State of Florida (depending on the board or committee on which I serve) on July 1st, following the closing of the calendar year on which I have served. Mr. Dale Stine Sworn to and subscribed before me this /0 day of 31 2017 JAN Deputy Clerk 5i'O'� *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 committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community. m MIAMIBEACH NAME: Stine Dale CITY OF MIAMI BEACH BOARD AND COMMITTEE APPLICATION FORM Last Name First Name Middle Initial HOME ADDRESS: 1573 Pennsylvania Ave. #1N Miami Beach Florida 33139 Apt No. Home No./Street PHONE: (305) 761-3253 (786) 276-6468 City dale@dalestine.com State Zip Code Home Business Name: Heart Prints, Inc. Work Address: 1573 Pennsylvania Ave. # 1N Email Address Position: President/Photographer Miami Beach FL 33139 Street City State Zip Code 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. • Resident of Miami Beach for a minimum of six (6) months Yes • Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes • Are you a registered voter in Miami Beach: No • (Please circle one): I am now a resident of: South Beach • I am applying for an appointment because I have special abilities, knowledge and experience. Please list below: Photographer - Dale Stine views the photographic lens through his creative, academic and professional experiences in the perf • Are you presently a registered lobbyist with the City of Miami Beach? 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) Choice 1: LGBTQ Advisory Committee Choice 2: Choice 3: • 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 Note: If applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Center: 1. Past service on the Youth Center Advisory Board: No Years of Service: 2. Present participation in Youth Center activities by your children No if yes, please list the names of your children, their ages, and which programs. List below: Child Name Age Program • Have you ever been convicted of a felony: No If yes, please explain in detail: • Do you currently have a violation(s) of City of Miami Beach codes: No If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money: No If yes, please explain in detail: • Are you currently serving on any City Boards or Committees: No If yes, which board? • What organizations in the City of Miami Beach do you currently hold membership in? • I am now employed by the city of Miami Beach: No Which department? • List all properties owned or have an interest in, which are located within the City of Miami Beach: Gender: Male 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. Race/Ethnic Categories What is your race? Mark one or more races to indicate what you consider yourself to be. White Other Description: Are you Spanish/Hispanic/ Latino? Mark the "No" box if not Spanish / Hispanic / Latino. No Physically Challenged: No NOTE: If appointed, you will be required to follow certain laws which apply to city board/committee members. These laws include, but are not limited to, the following: o 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). o Prohibition from lobbying before board/committee you have served on for period of one year after leaving office (Miami Beach Code section 2-26). o Requirement to disclose certain financial interests and gifts (Miami -Dade County Code section 2-11.1). (re: 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 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." I Dale Stine agreed to the following terms on Received in the City Clerk's Office by: Name of Deputy Clerk Control No. Date DALE STINE photographer Dale Stine views the photographic lens through his creative, academic and professional experiences in the performing arts. A North Carolina native who obtained a Master's Degree in Opera from the world-renowned Juilliard School (NY), Dale enjoyed a 16 -year run in many off-Broadway productions. Never one to pass up an opportunity to flex various muscle groups, Dale simultaneously pursued a dual career in personal training and fitness instruction. Self-taught in the fine art of digital photography, Dale quickly established himself as one of the most sought-after photographers in Miami. Since 2001, his photographs and images have graced countless magazines, cd covers and websites, including Wire, Ocean Drive, Men's Journal, Medesthetics, Home, DAYSPA and Genre. Internationally -acclaimed DJ's, drag personas and his 18 year-old cat Reba are among his favorite clients. Dale is one of the official photographers for the internationally -acclaimed South Beach Wine and Food Festival as well as Aqua Girl for the Aqua Girl Foundation, the Miami -Dade G/L Chamber of Commerce and for six years, the Miami G/L Film Festival. Just last fall, Dale was hired to shoot the New York City Wine and Food Festival, the only photographer from Florida to do so. Exhibitions have included The Diva Collection: Illusion Series, featured at the historic Royal Palm Hotel during White Party, The Starlet Series at Miami Beach Cinematheque, Communion Celebrates Art at the Bakehouse Art Complex, Decline in Civilization for Art Basel 2006 and A Different Angle for Art Basel 2008. "Whether I am photographing a person, an animal or a building, I do my best to connect with the essence of the subject. By allowing the "now" to unfold, I trust the intimacy of the moment to flourish for all to see." dalestine.com 305.761.3253 dale@dalestine.com MIAMI•DADE COUNTY SOURCE OF INCOME STATEMENT Section 2-11.1(i) of the County Ethics Code requires that certain employees and public officials file a financial disclosure Statement on a yearly basis by July lst of every year. Disclosure for Tax Year Ending Last Na e 2016l �! First Nami Middle Name/Initial Mailing Address — treet Number Street Name or P.O. Bo l'.93 �� . o .�a V NV City, State,.Zip f i\ I ccA.1 &f e'd) P 33 9 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. ❑ check one Filing as a Board Member (check one) County El Municipal: r i -P di (Municipality) Board where serving 76-tQ� U t 5. Alternate address (if home address is exempt) ork telephone 4/3l Term began on/ended 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. Examples of sources of income include: compensation for services, income from business, gains from property dealings, interest, rents, dividends, pensions, IRA distributions, and social security payments. Also, include any source of income received by another person far your h nefit Hoavever the incomz 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 II County E] Public Health Trust Municipal: (Municipality) (C:13 P-4/Ple \ i‘tz' --4/1° ry,ethl,,k Pmt, r�5 Department Position or Title Employee ID Number Work address Work telephone Employment began on/ended on Filing as a Board Member (check one) County El Municipal: r i -P di (Municipality) Board where serving 76-tQ� U t 5. Alternate address (if home address is exempt) ork telephone 4/3l Term began on/ended 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. Examples of sources of income include: compensation for services, income from business, gains from property dealings, interest, rents, dividends, pensions, IRA distributions, and social security payments. Also, include any source of income received by another person far your h nefit Hoavever the incomz 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 (1Q;rlftr:( 11.)")—J—he . (C:13 P-4/Ple \ i‘tz' --4/1° ry,ethl,,k Pmt, r�5 --pli.A5-1-q14449 ntuitAt, r-1/4.33 I hereby swear (or affirm) t t tfle information above is a true and correct statement. Signature of Person 0) 1a )� osing Date s' . ned RECEIVED BY ELECTIONS DEPARTMENT: ❑ Hardcopy ❑ Electronic Copy OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/Initials: iso SF- a COE2016 Scanned Date/Initials: MIAtv\1 BEACH 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) 1 Board Member's Name: "✓q k t 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" 2. A "Statement of Financial Interests (Form 1)" 3. A Copy of your latest 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. Signature Da Updated: Monday, April 20, 2015 Page 4 of 4 F \CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06022014.docx MIAM BEACH Name: DIVERSITY STATISTICS REPORTING LG visvfy Board / Committee: Appointment Date: t L 0-71-1/71rn [ t- e e) Pursuant to City of Miami Beach Ordinance 2009-3632, the City is required to annually prepare and present a report to the City Commission identifying the City's diversity statistics. This form allows board and committee applicants and members to voluntarily self -identify their race, ethnicity, disabled status and gender. Please check the appropriate box for each category: Gender: Male 11 Female Race/Ethnic Categories What is your race? frican-American/Black Caucasian/White LD Asian or Pacific Islander Native-American/American Indian Other — Print Race: Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No" box if not Spanish, Hispanic, Latino/a. No O Yes Do you consider yourself Physically Disabled? No D Yes C:\Users\CENTFraN\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\NP4J9CNX\BC minority information form 05-20-13 FINAL.doc Updated: Monday, January 26, 2015