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OFFICE
BOARD/COMMITTEE: C04/1.41'1c-4e Q i/,,� Appointed by: /3C�,vx,� 7
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FOR SCANNER
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FOR CLERK STAFF
o Letter of Appointment
o Letter of Reappointment
o r `ter ,of Appointment/Reappointment
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O Boarand ommittee Application (Completed on
o Resume/Curriculum Vitae
O Diversity Statistics Reporting (Completed on
o Oath
e-mailed to
Committee Liaison
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
✓ City Code Ordinance Section applicable to the agency, board or committee
✓ City Code Sections 2-21, 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459
✓ County Code Section 2-11.1 — Conflict of Interest and Code of Ethics Ordinance
amended through December 2010)
✓ Amendments to the Code of Ethics Ordinance (September 2009 through July 2012)
✓ Highlights of the Miami -Dade County Ethics Code
✓ Sunshine Law and Public Records — Frequently Asked Questions
✓ Memorandum - Solicitation by City Board and Committee Members
o Citywide Permit Application (Parking Department Form)
o Booklet — Guide to Sunshine Amendment & Code of Ethicsfor Public Officers !0ers and Employee:
o Source of Income Statement
o Acknowledgment of Financial Disclosure Requirement
o DI 'ERSITY STATISTICS
TING Keep, •'Y in file and ORIGIN
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Received on: / ( O /4- Signed by X / % tea,
Dat ) B• or om ! itte� Member
Processed on: (1 r ) v/ 7 By Employee:
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Scanned on: [ (/ Y/) (3/ ?By Employee:
Date Lett - ♦'Ice Staff lnii
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for Annual Report.
CONCLUDED & RESIGNA T ION LETTERS
Term Expired Letter
Resignation Letter Date Processed
Removal Letter due to absences
Date Processed
Date processed
FACLERiBOARD AND COMMITTIES DA T ABASE\CHECKLIST MASTER\B&C Checklist 2015 lh.docx
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MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139 www.miamibeachfl.aov
OFFICE OF THE CITY CLERK, Rafael E. Granado, City Clerk
Tel: 305.673.7411, Fax: 305.673.7254
Email: CityClerk@miamibeachfl.gov
October 02, 2017
Dr. Karmenchu Santana -Vega
RE: Committee for Quality Education in Miami Beach
Dear Dr. Karmenchu Santana -Vega:
Congratulations! You have been appointed by the Biscayne Elementary PTA to the agency, board or
committee named above fora term ending: 06/30/2018.
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 again and good luck.
Rafael Granado
City Clerk
cc: Saul Frances, Parking Director
Dr. Leslie Rosenfeld, City Liaison
ENCLOSURES:
Oath of Office/Oath of Civility/Acknowledgements
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
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.aov
OFFICE OF THE CITY CLERK, Rafael E. Granado, City Clerk
Tel: 305.673.7411, Fax: 305.673.7254
Email: CityClerk@miamibeachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Dr. Karmenchu Santana -Vega
RE: Committee for Quality Education in Miami Beach
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: 06/30/2018.
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 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.
Sworn to and subscribed before me this
les D'Agostin
eputy 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 committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community.
MIAMI BEACH
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Laslame
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Home Address
(01 ) g68 -a446,
Home Telephone Work Telephone
Business Name
Business Address
Professional License (describe):
BOARD AND COMMITTEE APPLICATION FORM
VIrY)PYAchE4
First Name Middle Initial
P/./ Hg /' /5et-4 3-7,141
City State Zi15 Code
ISQ/itynienq 046x -it
Cellular Teleph ne Email address A- 4 , i, ',t._/
k -e___ ec] H6cf Adrni/'/ISik-aTor
Occupation
City State
�', o -Y F/Y/°et.4)` pro /A • Expire
Please attach a copy of currently effectivefirofessional 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
• Demonstrates ownership/interest in a business in Mimi Beach for a minimum of six months: Yes La or No
• Are you a registered voter in Miami Beaches Ul or No LI
• I am now a resident of: North Beach 41 South Beach Middle Beach
• 1 applying for an appointor nt because I have special,abilities, knowledge and experience. Please list below:
Zip Code
/u rl.e 2 .9 2 2_
Mice'{' o'Y1 Aed1/11I Y11S'frao
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v , 4_ ed L t_C tt {{--i e �'� 1 /.l� Ot. in ell /1 1 m 1 <'Cf' a ie'
• Are you presently a registered lobbyist with the City of Miami Beach? Yes or No LZ
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.
D Affordable Housing Advisory Committee
D Art in Public Places Committee
D Audit Committee
D Board of Adjustment **
D Budget Advisory Committee
9 Committee on the Homeless
❑ Committee for Quality Education in MB /
D Convention Center Advisory Board
9 Cultural Arts Council
D Design Review Board*
D Disability Access Committee
❑ Health Advisory Committee
0 Health Facilities Authority Board
0 Hispanic Affairs Committee .2--
D
D Historic Preservation Board*
❑
Housing Authority
0 Human Rights Committee
9 LGBT Advisory Committee
0 Marine & Waterfront Protection Authority
❑ Miami Beach Commission for Women
0 Normandy Shores Local Government
Neighborhood Improvement
D Parks and Recreation Facilities Board
0 Personnel Board
0 Planning Board**
9 Police Citizens Relations Committee
0 Production Industry Council
0 Sister Cities Program
❑ Sustainability Committee
0 Transportation, Parking, & Bicycle -Pedestrian
Facilities Committee
0 Visitor and Convention Authority
0 Youth Commission
00
* 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
C:\Users\CLERQueR\Desktop\BC APPLICATION.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 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 felony? Yes U or No If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach Code? Yes IZi or Nodi If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money? Yes Li or No[If yes, explain in detail:
• Are you currently serving on any City Board or Committee? Yes 11 or No li 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 or No
ll(
Which department and title?
• Pursuant to City Code Section 2-25 (b): Do you have. --parent U, spouse U, 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 Female Ufdi
Race/Ethnic Categories
What is your race?
�African-American/Black
y
I Caucasian/White
ill
A Asian or Pacific Islander
Native-American/American Indian
Page 2 of 4
C:\Users\CLERQueR\Desktop\BC APPLICATION.docx
Other — Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No" box if not Spanish, Hispanic, Latino/a.
LJN
Yes
Do you gonsider 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 e ICERS, EMPLOYEES AND AGENCY MEMBERS AND ALL OTHER APPLICABLE COUNTY AND/OR STATE LAWS AND
S UTE$ ACCORDINGLY."
A ' p icant's Signature/
o ived in the Office of the
1
/! .4G/7 K Gt ��a Yl C — c�
Date PJatfie oA licant PLEASE PRINT
,11,16,35)C il/7
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
C:\Users\CLERQueR\Desktop\BC APPLICATION.docx
(305)868-8446
Y:
AWARDS:
CERTIFICATIONS:
EMPLOYER:
ADMINISTRATIVE
EXPERIENCE:
PROFESSIONAL
EXPERIENCE:
FCC LICENSE:
AFFILIATIONS:
EDUCATION:
Karmenchu Santana -Vega, Ed. D.
7441 Wayne Avenue, Apt. PH -C
lome) Miami Beach, FL 33141 (305)868-7727 (Work)
Experienced Assistant Principal, fluent in English and Spanish, with sixteen years of
accomplishments in the education. guidance and motivation of ethnically and culturally
heterogeneous groups. Consistently recognised for strong organization and
communication skills, computer knowledge and abilities, and a true commitment to the
highest ethical and professional standards. Recipient of nutnerous awards for outstanding
contributions to the community and to traditional values.
Dade County Francisco R. Walker 19981 Teacher of the Year - President William
Clinton's Letter of Recognition - Golden Rule Award - The WashingtonTimes
Foundation National Service Award - United Way's Green Family Foundation
American Values Award - Peace Foundation's Pcace Educator of the Year
Florida's Finest Certificate of Appreciation - Presented by Governor Lawton Chiles
American Red Cross Recognition Award - Points of Light Foundation's Silver Medal
- Hero Award - Certificates of Excellence from the Office of Multicultural Programs
City of North Miami Mayor's Certificate of Excellence
State of Florida Professional Certificate - Educational Leadership - Guidance/
Counseling Pk -12 - ESOL K- 12
Miand-Dade County Public Schools
Biscayne Elementary Community School, Miami Beach, FL
Community School Assistant Principal (March, 2001 - Present)
Broadmore Elementary School, Miami, FL
Assistant Principal (August, 1997 - March, 2001)
William Jennings Bryan Elementary School, Miami, FL
Guidance Counselor (1991 - 1997)
ES01, Teacher (199a 1991)
Citrus Grove Elementary School, Miami, FL
ESOL, Teacher K-6 (Spanish S.L.) (1988 - 1990)
New York City Board of Education, New York, NY
Classroom Teacher K & 3rd (1986 - 1988)
Radio Operator, Lifetime
Florida Association for Computers in Education - American Hiispanic Education
Association of Dade - Kappa Delta Pi - Women's Federation for World Peace - Pedro Pan
Ed. D./Educational Leadership
Date of degree, June 2002, Miami, Fl.
Nova Southeastern University
Educational Leadership Certification
Barry University Educational Leadership Program, December 1995, Miami, FL
Guidance K-12 Certification
Nova Southeastern University School of Psychology, December 1990, Miami, FL
Master of Science in Bilingual/Bicultural Education
St. John's University, December 1988, New York, NY
Bachelor of Arts In Sociology, minor in Foreign Languages
Herbert H. Lehman College, June 1974, New York, NY
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DIVERSITY STATISTICS REPORTING
Name: ,AP/4/1-e-)~ Sii-c) Ve3/-r
Edc-({4-7LICYL/ Board / Committee: C7 l��eC F40- afe -/�t-%
1
Appointment Date:
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 Li Female
Race/Ethnic Categories
What is your race?
F.D At -American/Black
CaucasianANhite
Asian or Pacific Islander
0 Native-American/American Indian
0 Other — Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No" box if not
Spanish, Hispanic, Latino/a.
es
Do you co ider yourself Physically Disabled?
No
0 Yes
CAUsers10E tNTF'raN\AppData\L ocatWilorosC)`nW indo'. s\Temoora Intarn et Ras ookV\IP4J9 1N 0 BC ;minority
information form 05.20.13 FINAL.doc
Updated: Monday, January 26. 2015
i1 BEAD
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(1) (2)
Board Member's Name:
KAM/ (54O-F/°t 4 Ve
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.
Updated: Monday, April 20, 2015
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