Martin Zaiac 12/31/19I A 1
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BOARD AND
OARDAND COMMITTEE CHECKLIST
APPOINTEE: /V " ' ` V �i�� DATE OF APPOINTMENT:
BOARD/COMMITTEE:2�ft CR50e-`7Appointed by: !
FOR SCANNER FOR CLERK STAFF
Scan o o Letter of Appointment TERM END: TERM LIMIT:
Scan c o Letter of Reappointment
o y f e of Appointment/Reappointment e- ailed to Committee Liaison on
Scan o o Board and Co mittee Application (Completed on
Scan o o Resume/Curriculum Vitae
o Diversity Statistics Reporting (Completed on
Scan o c Oath
0 Citywide Permit Application (Parking Department Form)
C Booklet — Guide to Sunshine Amendment & Code of Ethics for Publi fficers and Employees
Scan o C Source of Income Statement
Scan C o A knowledgment of Financial Disclosure Requirem
C IVERSITY STATISTICS REPORTING Keep P file W GINAL for Annual Report.
Received on: �91 Signed by X
te/ � /or C � e M
Processed on: / r By Employee:
ate% ff'ce Staff Initials
Scanned on: ((// By Employee:
Date C y Cl:; ' ffice Staff Initials
scanned
CONCLUDED & RESIGNATION LETTERS
Term Expired Letter
Date Processed
Initials Scan o
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
Date Processed
Initials Scan C
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✓
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
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✓
County Code Section 2-11.1 — Conflict of Interest and Code of Ethics Ordinance (as
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amended through December 2010)
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Amendments to the Code of Ethics Ordinance (September 2009 through July 2012)
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Highlights of the Miami -Dade County Ethics Code
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✓
Sunshine Law and Public Records — Frequently Asked Questions
_
Memorandum - Solicitation by City Board and Committee Members
0 Citywide Permit Application (Parking Department Form)
C Booklet — Guide to Sunshine Amendment & Code of Ethics for Publi fficers and Employees
Scan o C Source of Income Statement
Scan C o A knowledgment of Financial Disclosure Requirem
C IVERSITY STATISTICS REPORTING Keep P file W GINAL for Annual Report.
Received on: �91 Signed by X
te/ � /or C � e M
Processed on: / r By Employee:
ate% ff'ce Staff Initials
Scanned on: ((// By Employee:
Date C y Cl:; ' ffice Staff Initials
scanned
CONCLUDED & RESIGNATION LETTERS
Term Expired Letter
Date Processed
Initials Scan o
Resignation Letter
�
Date Processed
Initials Scan C
Removal Letter due to absences
I
Date processed
Initials Scan o
F 1CLER\$ALL\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
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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
July 26, 2018
Mr. Martin Zaiac
4308 Alton Road, Suite 750
Miami Beach, FL 33140
RE: Health Advisory Committee
Dear Mr. Martin Zaiac:
Congratulations! You have been appointed by the City Commission to the agency, board or committee
named above for a term ending: 12/31/2019.
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.
RIfael"'Granado
gars,
City Clerk
cc: Saul Frances, Parking Director
Sonia Bridges, 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.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
TO: Mr. Martin Zaiac
RE: Health 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: 12/31/2019.
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.
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 ty e
State of Florida (depending on the board or committee on which I serve) on July 1 st, foil i t �ing
of the calendar year on which I have served.
Mr. Martin mac
Sworn to and subscribed before mthis 3��//ayf 2018
Clerk
*Please visit the City of Miami Beach website at www.miamibeachfi.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.
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.gov
CITY CLERK'S OFFICE
Telephone: 305.673.7411 Fax: 305.6737254
CityClerk@miamibeachfl.gov
Acknowledgement of fines/suspension for Board/Committee Members for failure to comply with Miami -
Dade County Financial Disclosure Code Prov' ion Code Section 2-11.1(1) (2)
Board Member's Name: �V i"',
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 Fourn
Failure to file one of these forms, pu
of no more than $500, 60 days in jail /4
Signature
Updated: Thursday, December 28, 2017
i -Dade County Code, may subject the person to a fine
Page 4 of 4
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06022014.dccx
//N
Date
M, I A MI E A
DIVERSITY S ATISTICS REPORTING
Name:
Board / Committee:
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 Female D
Race/Ethnic Categories
What is your race?
Afr' an-American/Bl- k
ID CaucasiaNWhiter C
Asian or Pacific Islande
Native-American/American indian
Q Other — Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mari; the ",No" box it not
Spanish, Hispanic, Latinofa.
�.No Ij
0 Yes 5/*
Do you nsider yourself Physically Disabled?
No
Q Yes
inforrnation form 05.20-13 FINAL.doc
tjnda.-,J: ;lAon_,vy January ?�, 2015