Lauren Cantor 06/30/22 MAMHBEACH
BOARD AND COMMITTEE CHECKLIST
APPOINTEE: LL% # e ,.`` DATE OF APPOINTMENT: `��� 7/62-a:)/
BOARD/COMMITTEE: Oti I l ,,4 Appointed by: ' _ret i11 Nt Cci Fkii '� j) "
FOR SCANNER FOR CLERK STAFF
Scan o o Letter of Appointment TERM END: 7:3C)/d-)-. TERM LIMIT: /..30/4„)
Scan o o Letter of Reappoin ment
o y lett ofdpgoir ment/Reappointment e-mailed to Committee Liaison on
Scan o o Beard and Committee Application (Completed o
pp P )
Scan o o Resume/Curriculum Vitae �/
o Diversity Statistics Reporting (Completed on )
Scan o o Oath
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
V 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
RECEIVED ✓ 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)
JUN2 . 2021 ✓ Highlights of the Miami-Dade County Ethics Code
V Sunshine Law and Public Records-Frequently Asked Questions
CITY OF MIAMI BEACH ✓ Memorandum-Solicitation by City Board and Committee Members
OFFICE nr THE CITY CLERK
O Citywide Permit Application (Parking Department Form)
o Booklet-Guide to Sunshine Amendment&Code of Ethics for Public Officers and Employees
Scan 0 0 Source of Income Statement
Scan 0 0 Acknowledgment of Financial Disclosure Requirement
0 DIV RSITY STATISTICS RE�PPORTI G Keep COPY file and ORIGINAL for Annual Reports
�� '
Received on: / ( Signed by/\ �/ � >
Rl°-L�f��l
Date ;9ard or Com r'tee
Processed on: (?l /9 'c (By Employee: / �
Date `#'•rk's Office taff •
-
Scanned on: / 10-� By Employee:
Pi Ai
Date 11 ity s Office Staff Initials
CONCLUDED & RESIGNATION LETTERS
Term Expired Letter Date Processed
Initials Scan 0
Resignation Letter Date Processed Initials Scan 0
Removal Letter due to absences Date processed Initias Scan 0
F:\CLER\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTERIB&C Checklist 2015 MASTER.docx
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City of Miami Beach, rm.)Converntion CFanlcsr Driver,Miami Bach,Flora&a 33139 a::..w.miamihcach1lmov
OFFICE OF THE CITY CLERK,Rafael E.Granada,City Clork
Td:305.673.74 11,Fax:305.6732254
Email:Ci1yCiark niamiboachll.go
Oath of Office
Oath of Civility
and
Acknowledgements
TO:Ms.Lauren Cantor
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:06/30/2022.
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.
Ms. Lauren Cantor ~
Sworn to and subscribed before me this/ -r day of�21
I.APP
Charm 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.
`\ N BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC(@,,miamibeacht1.Qov
Telephone:305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (✓) all that apply):
`' am a resident of the City of Miami Beach for six months or longer.
❑ I have an ownership interest (for a minimum of six months) in a business established in the
City of Miami Beach (for a minimum of six months).
❑ I am a full-time employee of a business (for a minimum of six months) and I am based in an
office or other location of the business that is physically located in Miami Beach (for a
minimum of six months).
"Ownership Interest" means the ownership of ten percent (10%) or more (including the
ownership of 10% or more of the outstanding capital stock) in a business.
"Business"means any sole proprietorship, sponsorship, corporation, limited liability company,
or other entity or business association.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts
stated it are true. /(f�{
A y �y
cit ' r `i(` ,� 0_
1
Signature Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of(ysical presence or 0 online
notarization, this/2/ 'day of ��-°L11 G , 20-2'(by
/_ -L4'f?/_-A! (7,,,ii 1 f (City of Miami Beach Board/Committee Member).
J� Produced ID j � • cf 1."-S !—/CP/)
Form of Id ratification
_ P-r.on, now
. (NOTARY SEAL)
Signat' .'`No : Public ApRy, , Charles J.DAgostin
Q� ' NOTARY PUBLIC
�V•�y
Name of Notary, Typed, Printed, or Stamped � _
�,. ESTATE OF FLORIDA
• Comm#GG168171
' VCE 191% Expires 12/14/2021
AA AMIbE
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.aov
Telephone: 305.673.7411
BOARD &COMMITTEE FINANCIAL ACKNOWLEDGEMENT STATEMENT
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)
Last Name First Name Middle Initial
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.
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;" or
2. A"Statement of Financial Interests (Form 1)1;" or
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
ofno ore than $500, 60 days in jail, ,r both.
tai r .. ,(1.4. . r ( --/
Signature Date
Members of the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuant to F.S. §112.3145(1)(a),to file a Statement of Financial Interests(Form 1)with the Miami-Dade County
Supervisor of Elections by 12:00 noon, July 1. Planning Board and Board of Adjustment members who file their
Form 1 with the County Supervisor of Elections automatically satisfy the County's financial disclosure
requirement as a Miami Beach City Board/Committee member and need not file an additional form with the Office
of the City Clerk. However, compliance with the County disclosure requirement does not satisfy the State
requirement.
Page 5 of 6
F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated:June 2020
Iv\ AM ' F A CH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www miamibeachfLsov_
OFFICE OF THE CITY CLERK
Email:BC miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
Last Name First Name Middle Initial
The following information is voluntary and has no bearing on your consideration for appointment. It is being
asked to comply with City diversity reporting requirements.
Gender:
Male
1.. Female
.Other
i._.1. I prefer not to answer.
Race/Ethnic Categories:
What is your race? •
0 African American/Black
Asian or Pacific Islander
RCaucasian/White
° Native American/American Indian
L I Other—Print Race:
U I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
DA Yes
._1 No
I prefer not to answer.
Do you consider yourself Physically Disabled?
1_ i!yes
.-2I:_i No
LI I prefer not to answer this question.
Page 6 of 6
F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated:June 2020
I f\j\ '~.;; a CITYWIDE (CW) BOARD & COMMITTEES - p
City of Miami Beach,PARKING DEPARTMENT PARKING APPLICATION - r
1755 Meridian Avenue,Suite 200/Miami Beach,FL 33139/Ph:(305)673-7505 or(305)673-7000 ext.6200 PARKING
A citywide (CW) parking permit is honored at metered parking spaces and restricted residential zones
parking spaces. A CW parking permit IS NOT honored in prohibited areas. An Access Card will be
provided to you for City Hall Garage (G7) access.
IMPORTANT NOTE: Your vehicle license plate serves as your "parking permit". In order to avoid
any unnecessary enforcement actions, it is important that our records reflect the most current and
accurate information regarding your vehicle license plate. Inaccurate and/or outdated vehicle
information may lead to the issuance of parking citation(s) and/or the towing of your vehicle.
Please note that this new access card CANNOT be hole-punched or perforated in any manner. To use
the new card please hold the card at close proximity to the reader until the gate opens. You may need
to try the other side of the card. Please ensure you hold the entire surface of the card against the reader
until the gate opens.
ACKNOWLEDGEMENT: I acknowledge that should my access card be lost, stolen or
damage, I will be responsible to pay a $10.00 replacement fee.
Board Member Information
Date of Application:
Applicant Name:
1,..mi----
A�_,..re i- CG .(� - \--I--
Board/Committee
--I—dBoard/Committee Name: t`AC
,At_� ^`C:.j.. 0,...;-3- r. (` r-,�-�r--, r.VI-1 'e
Address: GC-- c `, \:, Com° r, M,avY`,t
E-Mail Address: t
Work Phone: # 'I Tome Phone
Cell Phone: -- ? -- --)11- \ Gt Preferred Coit,ct�lJ�letht d,:
Vehicle Information CC \ 1^
Tag: fS V-..-,3"---7
----7 Color:
State: S--'-) L— Year: `'} N
Cl i
Make: erc Model: �c.A..."kit)k)(
Applicant Signature: .es f - .{�� `�, t -Er ....
Please provide signed form to the Parking Department located at 1755 Meridian Avenue, 2nd floor. Working
hours are 8:30 to 5:00 p.m. or email to: ParkingReception@miamibeachfl.gov
e-mail subject: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
Parking Department Section ___________________
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: __, _ ID Card Serial #:
Issued By Print Name: Print Name:
Signature: _es Signature: ,es
Date Issued: Date Completed:
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