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Judith Rosen 12/31/18MIAMIBEACH Cif-, of Miami Beach r 70 Lc^verbo, �.erl,, we. OFFICE OF THE CITY CLERK, Rafoel E. Granada, City Clerk Tel: 305.673.741 1, Fax: 305.673.7254 Email: CityClerk@m;om;beochfl.gov April 25, 2017 Ms. Judith Rosen RE: Sister Cities Pro4ram Congratulations! You have been appointed by Mayor Philip Levine to the above -referenced Board or Committee, for a 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 as they concern your duties, responsibilities, and requirements as a board or committee member. Congratulations and good luck. Regard , Raf el Granado City Clerk cc. Saul Frances, Parking Director Danila Bonini, City Liaison ENCLOSURES: Oath of Office/Oath of Civility/Acknowledgements City Code/Ordinance section applicable to agency, board or committee City Code Sections 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 Citywide 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 pubirc servee and safety to an who live, work and play in our v;bran; !ron cal h;stonc cornmuney WAMBEACH City of Miami Beach, 1700 Convert cn Cera• P,1 Roc,-, v' �^Gonda 33139 o, OFFICE OF THE CITY CLERK, Rafael E. Granada, City Clerk Tel: 305.673.7411, Fox: 305.673.7254 Email: CityClerk@miomibeochfl.gov April 25, 2017 Ms. Judith Rosen RE: Sister Cities Program Congratulations' You have been appointed by Mayor Philip Levine to the above -referenced Board or Committee, for a 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 appointmenUelection 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 as they concern your duties, responsibilities, and requirements as a board or committee member. Congratulations and good luck. RegarlGranado Raf el City Clerk cc: Saul Frances, Parking Director Danila Bonini, City Liaison ENCLOSURES: Oath of Office/Oath of Civility/Acknowledgements City Code/Ordinance section applicable to agency, board or committee City Code Sections 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 Citywide 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 ercevent pubirc Serwce and safety to a,; who live work and play to our vzrant tropical h;sforrc communey MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139 www.miamibeachfl.gov OFFICE OF THE CITY CLERK, Rafael E. Granada, City Clerk Tel: 305.673.7411, Fax: 305.673.7254 Email: CityClerk@miamibeachfl.gov Oath of Office Oath of Civility and Acknowledgements RE: Sister Cities Program 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. To my colleagues and to all of those I represent and serve, I pledge fairness, integrity and civility, in all actions taken and all communications made by me as a public servant. I hereby acknowledge that 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 that I understand that as a member of the above -referenced City of Miami Beach Board 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. Ms. Judith Rosen Sworn to and subscribed before me this G7' day of_ 12017 on Quez a Deputy Clerk We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community. MIAMI. BOARD AND COMMITTEE APPLICATION FORT' a6eN :3 U-1 k!�o 1-11 Last Name First Name Middle Initial Home Address City State Zip Code Q5 c�(O-b3y� 12C-e6,6C\c-600,0t,c-Drn Home Telephone Work Tele hone Cellular Telep'one Email address ^_ Business Name Oc pationn Flo �S me.rt&w (A. 1. R -f 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. • Resident of Miami Beach for a minimum of six (6) months: Yes or No ED • 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. Yes or No U • I am now a resident of: North Beach South Beach Middle Beach • I am applying for ary appointment because) 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 Office of the City Clerk. ❑ Affordable Housing Advisory Committee ❑ Health Advisory Committee D Parks and Recreation Facilities Board cO ❑ Art in Public Places Committee ❑ Health Facilities Authority Board ❑ Personnel Board ❑ Audit Committee D Hispanic Affairs Committee ❑ Planning Board* ❑ Board of Adjustment ❑ Historic Preservation Board ❑ Police Citizens Relations Committee ❑ Budget Advisory Committee ❑ Housing Authority D P uction Industry Council ❑ Committee on the Homeless ❑ Human Rights Committee VoSister Cities Program ❑ Committee for Quality Education in MB ❑ LGBT Advisory Committee D Sustainability Committee ❑ Convention Center Advisory Board ❑ Marine & Waterfront Protection Authority D Transportation, Parking, & Bicycle -Pedestrian Facilities Committee ❑ Cultural Arts Council ❑ Miami Beach Commission for Women ❑ Visitor and Convention Authority ❑ Design Review Board ❑ Normandy Shores Local Government ❑ Youth Commission Neighborhood Improvement ❑ Disability Access Committee * 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:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06142016.docx °O Note: If applying for the Youth Center positions of the Parks and Recreations Facilities Board, please indicate your affiliation with the Scott Rakow Youth Center and/or the North Shore Parks Youth Center: • Please describe your past service with the City's Youth Centers (include dates of service): • Present participation in Youth Center activities by your children: Yes �J No If yes, please list below the names of your children, their ages and the programs in which they participate: Child's name: Child's name: Age: Program: Age: Program: • Have you ever been convicted of a felonv? Yes L__J or No LV_J If ves_ nlease exnlain in detail: • Do you currently have a violation(s) of City of Miami Beach Code? Yes or N If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money? Yes or No 011f yes, explain in detail: • Are you currently serving on any City Board or Committee? Yes or No If yes, which board/committee? • In what organization(s) in the City of Miami Beach do you currently hold membership? Name Position Name Position • Listalp©�r�s ohvnej o� iiw`hi;�ou fjav�e a�n� teres[w>�i� City o� �Miam�i Beacy� • Are you now employed by the City of Miami Beach? Yes or No Which department and title? • Pursuant to City Code Section 2-25 (b): Do you have a parent , spouse 12 child brother or sister who is employed by the City of Miami Beach? Yes Uor No 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 L1 Female Race/Ethnic Categories What �its your race? African-American/Black L_;,1 Caucasian/White Asian or Pacific Islander Native-American/American Indian Page 2 of 4 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06142016.docx ID Other — Print Race: Do�you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No" box if not Spanish, Hispanic, Latino/a. 'i No 1-3 Yes Doyou onsider 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). o Prohibition from contracting with the City (Miami -Dade County Code section 2-11.1). o 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). o Requirement to disclose certain financial interests and gifts (Miami -Dade County Code section 2-11.1). o 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). o 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. o 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 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 OFFICERS, EMPLOYEES AND AGENCY MEMBERS AND ALL OTHER APPLICABLE COUNTY AND/OR STATE LAWS AND STATJJ+ES ACCORDINGLY." J.11 �l%l6 V � wN t-�h WN,."Q 6-e-10 Name of Applicant (PLEASE PRINT) Applj4ayft's Signature in the Office of the City Clerk by: Date Name of Deputy Clerk Control No. Date 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 06142016.docx - Tn MIAMI. SOURCE OF INCOME STATEMENT Section 2-11.1(1) of the County Ethics Code requires that certain employees and public officials file a financial disclosure Statement on a yearly basis by July 1st of every year. Disclosure for Tax Year Ending TL�t Name First Name Middle Name/Initial 2016 Mailing Address — Street Number, Street Name, or P.O. Box 5�'oS-� City, State, Zip � � � � L to If your home address is your mailing address, and your me address is exempt from public records pursuant to Fla. Stat. §119.07, read instructions on the following page and check here. Filina as an Emminvee (check onel F County F Public Health Trust Municipal: (Municipality) Department Position or Title Employee ID Number Work address Work telephone Employment began on/ended on Filing as a Board Member (check one) Eff'*County alp, EMunicipal: (Municipality) Board where serving Alternate address (if home address is exemA Work telephone Term began on/ended on -5' 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 nersnn for vniir henefit. However. the income of vour snouse or anv 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 sub � � s-jp � () 6 LLA� � �0 OL ��� Re" -t I hereby swear (or affirm) tli fit the information above is a true and correct statement. atur of Person Disclosing 7 l7 Date signed RECEIVED BY ELECTIONS DEPARTMENT: ❑ Hardcopy ❑ Electronic Copy OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/Initials: Scanned Date/Initials: 138 SP -14 COE 2016 City of Miami Beach 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov OFFICE OF THE CITY CLERK 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: 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. 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. 10 Updated: Wednesday, November 23, 2016 Page 4 of 4 FACLER\$ALL\aFORMS\BCARD AND COMMITTEES\BC APPLICATION REVISED 06142016.docx Al / Q-�)) -r Date t Name: DIVERSITY STATISTICS REPORTING -�� 4�0 Board / Committee: Appointment Date: YZ 2 --�,z/ 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 ED Female Race/Ethnic Categories What is your race? rican-American/Black Caucasian/White ID Asian or Pacific Islander Native-American/American Other — Print Race: Indian Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No" box if not r Hispanic, Latino/a. Yes Do, you consider yourself Physically Disabled? 4 No ZJ Yes Signature: Date: F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEESWISC\BC minority information form 05-20-13 FINAL.doc Updated: Wednesday, June 25, 2014