Loading...
Harvey Burstein Application Package Page 1 of 4 C:\Users\CLERQueR\Desktop\BC APPLICATION.docx BOARD AND COMMITTEE APPLICATION FORM Last Name First Name Middle Initial Home Address City State Zip Code Home Telephone W ork Telephone Cellular Telephone Email address Business Name Occupation Business Address City State Zip Code Professional License (describe): Expires: Please attach a copy of currently effective professional license. 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. Page 2 of 4 C:\Users\CLERQueR\Desktop\BC APPLICATION.docx ● Have you ever been convicted of a felony? Yes or No If yes, please explain in detail: ● Do you currently have a violation(s) of City of Miami Beach Code? Yes or No If yes, please explain in detail: _________________________________________________________________________________________________________________________________________________________________________________________________ ● Do you currently owe the City of Miami Beach any money? Yes or No If 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 ● 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 W hich 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? Yes or 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 Race/Ethnic Categories What is your race? African-American/Black Caucasian/White Asian or Pacific Islander Native-American/American Indian ∞ 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: ___________________________________________ _______________________________________________________________________________________________________ x Please describe your past service with the City’s Youth Centers (include dates of service): _______________________________ _______________________________________________________________________________________________________ x Present participation in Youth Center activities by your children: Yes No If yes, please list below the names of your children, their ages and t he programs in which they participate: Child’s name: ________________________________________ Age: ______ Program: _________________________________ Child’s name: ________________________________________ Age: ______ Program: _________________________________ Page 3 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. No Yes Do you consider yourself Physically Disabled? No Yes 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.” _________________________________________________________________________________________________________________________ Applicant’s Signature Date Name of Applicant (PLEASE PRINT) Received in the Office of the City Clerk by: _________________________________________________________________________ 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. 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. Harvey J. Burstein Page 4 of 4 C:\Users\CLERQueR\Desktop\BC APPLICATION.docx 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. 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 Date Updated: Thursday, December 22, 2016 Harvey J. Burstein, Miamiartzine.com Publsher and Chair of Miami Beach Arts Trust Harvey J. Burstein is the chair of the Miami Beach Arts Trust (MBAT). He is the founder and publisher of Miamiartzine.com, and has a long history of philanthropy that began in Chicago with the sponsorship of Open Hand Chicago, AIDS Living Remembrance Project, Lesbian commutnity Cancer Project, AIDS Walk Chicago, Dance for Life Chicago, Jewish AIDS Network, Names Project, Joffrey Ballet. In addition, Harvey produced at Victory Gardens and Bailwick Theatre. Upon relocating to Miami a decade ago, Harvey co-founded the Miami Gay & Lesbian Film Festival and founded South Florida Dance for Life. Harvey has sponsored and/or volunteered at South Beach AIDS Project, Swim for Life, First Night, SAVE Dade, Carbonell Awards Committee, Florida Room Film Festival, Miami Light Project, Pridelines Youth Services and Ballet Gamonet. Harvey is currently on the advisory board of Dance Now and is VP of Collins Park Neighborhood Association. Harvey Burstein has received honors including the Horizon Community Services Chicago Community Spirit Award (2002), DCA Ambies Ambassador of the Arts Unsung Hero Award (2002), and Miami-Dade Gay & Lesbian Chamber of Commerce Leadership and Support Awards (2006). Harvey is director of the Burstein Family Foundation, founded by his late father.