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Michael Goldberg 12/31/18MIAMIBEACH BOARD AND COMMITTEE CHECKLIST APPOINTEE: v�GyL per, DATE OF APPOINTMENT: l b- BOARD/COMMITTE " Appointed by:�� FOR SCANNER FOR CLERK STAFF Scan o o Letter of Appointment TERM END: I`• TERM LIMIT: Scan o o Letter of Reappointment o Co o e r of Appointment/Reappointment -mail d to Committee Liaison on Scan o o Board and Committee Application (Completed on ( ) Scan o o Resume/Curriculum Vitae o Diversity Statistics Reporting (Completed on ) Scan ono �.;-w o Oath IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK nom.-�3 ✓ 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 I ✓ County Code Section 2-11.1 — Conflict of Interest and Code of Ethics Ordinance (as amended through December 2010) ✓ Amendments to the Code of Ethics Ordinance (September 2009 through July 2012) CXP ✓ 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 Ethics for Public Officers and Employees Scan o o Source of Income Statement Scan o o Acknowledgment of Financial Disclosure Requirement r o DIVERSITY STATISTICS REE/J PORT Keep COPY i ile and ORIGINAL for Annual Report. Signed b 9 Y X Received on: 1 J� Si Date Board or Committe Memb Processed on: Cs / " ©q` of By Employee: D to it C k's Office S ff i als Scanned on: / / � By Employee: Date ler ' ffice Staff iiif Is CONCLUDED & RESIGNATION LETTERS Term Expired Letter Date Processed I Initials Scan o Resignation Letter Date Processed Initials Scan o Removal Letter due to absences Date processed Initials Scan o F:\CLER\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx J 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 rniamibeachfl.aov OFFICE OF THE CITY CLERK, Rafael E. Granada, City Clerk Tel: 305.673.7411, Fax: 305.673.7254 Email: CityClerk@miamibeachfl.gov January 03, 2018 Mr. Michael Goldberg 11480 North Bayshore Drive North Miami, FL 33181 SUBJECT: Convention Center Advisory Board Congratulations! You have been reappointed by Commissioner Mark Samuelian to the above referenced, board or committee named above, 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 rJanuaryf 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 4Regards,V cc: Saul Frances, Parking Director Eva Silverstein, 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 vvww.miamibeachfl.aov OFFICE OF THE CITY CLERK, Rafael E. Granada, City Clerk Tel: 305.673.741 1, Fax: 305.673.7254 Email: CityClerk@miamibeachfl.gov Oath of Office Oath of Civility and Acknowledgements TO: Mr. Michael Goldberg RE: Convention Center Advisory Board 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 ana 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 1 st, following the closing of the calendar year on which I have served. , fiLZ11 Mr. Michael Goldberg Sworn to and subscribed before me this day of__ , 2018 Deputy Clerk SkvAji�j.�- '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. AMI FAC"H DIVERSITY STATISTICS REPORTING Board / Committee: `:�— c a 6 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 10 Female 0 Race/Ethnic Categories What is your race? African-American/Black Caucasian/White Asian or Pacific islander Native-American/American Indian Other — Print Race: Do you consider yourself to be Spanish, Hispanic or Latina/a? Mari. the "No" box i; not Spanish, Hispanic., Latinola. No 1-3 Yes Do you consider yourself Physically Disabled? N o Yes �,US (S1C IVT (c"i+ fru cCdtt OCai+iVi;Cr soft i^lirit� V•;S1T$riip0 fV lnt ill_ei r Inc^StGC(lic C. Ui}C3Jku 7 is uid;:+.art i; i; it�' information form 05-20-13 FINAL.doc Updated: Monday, Janua ny 26, 2015 City of Miami Beach 1700 Convention Center Drive Miami Beach, Florida 33139 www.miamibeachfl.aov CITY CLERK'S OFFICE Telephone: 305.673.7411 Fax: 305.673.7254 CityClerk@miamibeachfl.gov 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: L I understand that no later than July 1, of each vear 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. Signature Updated: Thursday, December 28, 2017 Page 4 of 4 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06022014.docx JJo/ Date ai C: -O V L 0 LL z c� ai ao Z Z Z Z 00 ON N N C) O O O O N N N N CN - N O co M co M N N SZ � N N f� L- Mr7l Z Qcu t-- 0 O O• O O N N u N N Q) C MMnTlll M M N NN N c � Z c0 r (D 0 a) EO ca Z a) a) cu c J c n () c0 O a) FL O S? "a S? Q a) C a) Z Q cu70 cuu a) ~ c d LL O o C Y a) Z a) cu O o Z 0 - CU cU a) (D } Z >1 Z Z �- M Ch M (Y) r O cu O O O O O O Q N N N N N N N M M M C\ C\7 M M J N (N N N N N N E a) H C C O O O O O O O LL N N N N N N N N EQ C'7 C\7 co . Ch (Y) M co O N N N N N N N CU O c6 E �0 3 o c Z cc m fA c R U N L _ O 7 L• i Y m _ • �� J H m (� C 0 m c Al P'amlp--A N N :D O 14 N '') M V N ti r D O V) C`7 14 N y a) PIAMOR." N O O N N M M N N � � � � O O N N r c - M M N N d t 7 E d a C: -O V L LL c� Z Z Z Z 00 ON N N O O O O N N N N co M co M N N N N f� L- Mr7l Il- t-- 0 O O• O O N N u N N MMnTlll M M N NN N c � _ r d t 7 E d a