Gavin Basner 06/08/22MIAMI RFACH
BOARD AND COMMITTEE CHECKLIST
APPOINTEE:_ tP �Ul n 6 aS per DATE OF APPOINT M T:
BOARD/COMMITTEE: �+ CD , SSl d A ointed b : QO�V (, ' L6' r S n
n.l� 1' 1 M pp Y
FOR SCANNER FOR CLERK STAFF�d
Scan o o Letter of Appointment TERM END: - Zpaz TERM LIMIT:
Scan o o Letter of Reappointment
n rYY Jett r f �Appo�'ntment/Reappointment e- ailed to Committee Liaison on
Scan o o Boar and o mitteA plication (Completed on
Scan o o R6sum&Curriculum Vitae
o Diversity Statistics Reporting (Completed on '_-';� L�l
Scan o o Oath
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 (as
amended through December 2010)
✓Amendments to the Code of Ethics Ordinance (September 2009 through July 2012)
AUG 2c') �aZ� ✓ Highlights of the Miami -Dade County Ethics Code
✓ Sunshine Law and Public Records — Frequently Asked Questions
f.`I', "'` 1/i8"''�i�►-! ✓ Memorandum - Solicitation by City Board and Committee Members
lir.;
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
O DIVERSITY STATISTICS REPORTING XOPCOPY in file and ORIGINAL for Annual Report.
Received on: Ia I a1 Signed by
Date Bo r�or ommi r
Processed on: By Employee:
Date i Office St-Irrtfiis
Scanned on: / --,I/ By Employee:
Date itv er ' O Ice Staff Initials
CONCLUDED & RESIGNATION LETTERS
Term Expired Letter
Date Processed
Initials Scan o
Resignation Letter
Date Processed
Initials Scan O
Removal Letter due to absences
Date processed
Initials Scan o
F:ICLERIBOARD AND COMMITTIES DATABASEICHECKLIST MASTERIB&C Checklist 2015 MASTER.docx
We are committed to providing excellent public service and safety to all who live, woA, and ploy in our vibrant, tropical, historic community
iMI A �MI B EA C H
City of Miami 600ch, I AX) Gorar,r+o+an C AKhN DVW, Moomf Bari, ftroda 93139 www.mia�.bcnciA.w�r
OFFICE OF THE MY CIkRK, tdod E Gf=3da, Ciy CIP4
Id 30 677 7411. Fuc 31)5 673-7254
I" ClyCk *k@w oo h$ gor
Oath of Office
Oath of Civility
and
Acknowledgements
TO. Mr. Gavin Basner
RE: Youth Commission
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: 06108/2022.
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 1 st, following the closing
of the calendar year on which I have served.
r: in Basner
rj
Sworn to and subscribed before me th�s79-2,_ day of A,,,,i.1, 2021
Agostin
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.
Clear From Print Form ,
MIMI®� SOURCE OF INCOME STATEMENT
Section 2.11.1(i) of the County Ethics Code requires that certain employees and public officials file a financial disclosure Statement on a yearly basis by July 1st
Disclosure for Tax Year Ending La Name First Name Middle Namefinitiai
2020 �S G Gad
Mailing Address — Street Number, Street Name, or P.O. Box
5'R-�\
City, State, Zip 1
A',amt
if vni❑ hnma addrpc-, is your mailino address, and your home address is exempt from public records pursuant to Fla. Stat. §119.07, read
instructions on the following page and check toe.
Q County ❑ Public Health Trust ❑ Municipal:
(Municipality)
Department
Position or Title
Employee ID Number
Work address
Work telephone
Employment began onlended on
Filino as a Board Member (check one)
Q County Q/Municipal: CL i
(Municipality)
Board where serving
3 'i Co 'i
Alternate address (if home address is exempt) Work telephone Term began on/ended on
UA AIS ors 3o5,a4 6 - AL's4 �k a
List below every source of income you received, along with the address and the principal activity of each source. Include your public salary. Place the sources of
income in descending order, with the largest source first. Examples of sources of income include: compensation for services, income from business, gains from
property dealings, interest, rents, dividends, pensions, IRA distributions, and social security payments. Also, include any source of income received by another
person for your benefit. However, the income of your spouse or any business partner need not be disclosed. If continued on a senarate sheet. cherk harp f—I
Name of Sourceof Income
Address
Description of the Principal Business Activity
M�aMO CCAA0 TCC
9a°�� p��� TS�e.'��
Cojn��[or
I hereby swear (or affirm) that the information above is a true and correct statement.
Signature of Person Disclosing
D�i/ 7
Dates Wined
RECEIVED BY ELECTIONS DEPARTMENT:
Cl Hardcopy F, t.; %
(. L IV D
L7•Electronic Copy
AUG L 20?1
CITYWIDE (CW) BOARD & COMMITTEES
MIAMI BEACH KING APPLICATION
City of Miami Beach, PARKING DEPARTMENT PAR PARKING
1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/Ph (305) 673-7505 or (305) 673-7000 ext 6200
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.
DOWU ITICIINUCI nnvrnlvrlvn _
Date of Application: $ a31 a
Applicant Name: 6(9\Vy f+ 66j Sp-V�,r-
Board/Committee Name:
CO Si _-
Address: 5q3A 06(,k h � �
E -Mail Address: Z rn►1 L
Work Pho e:
Home Phone qoc ^-661
Cell Phone:/305
� a 5 yah � -- � � �
Preferred Contact Method: Ce 1� Pi�vne--
.,..1-:_1.. I. -l_ —a:_
------._ ...------------
Tag: UW 6L�
GARAGE ACCESS
Calor:
ID Card Serial #:
State: Opi )0\
Print Name:
Year:
In
Signature:
Make:
Date Completed:
Model:
U t
Applicant Signature.: d
Please provide signed form to the Parking Department located at 1755 Meridian Avenue, 2^d floor. Working
hours are 8:30 to 5:00 p.m. or email to: ParkingReception@miamibeachfi.gov
e-mail subject: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
De.rV:n� n---rimont C-rti—n
PERMIT SYSTEM
GARAGE ACCESS
Expiration Date:
ID Card Serial #:
Issued By Print Name:
Print Name:
Signature:
In
Signature:
Date Issued:
Date Completed:
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BCI miamibea0 l gay
Telephone. 305.673.741 1
STATE OF FLORIDA
COUNTY OFN\ ,A, M
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as /(check (J) all that apply):
L� I 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).
❑ 1 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 in"re re true.
Signature
Coaly I\, -A 6-,
Printed Name
Date
Sworn to (or affirmed) and subscribed before me, by means of Cl physical presence or NI online
notari6
zation, this o2` d/ay of 20.Z1 by _
/' I L1 ^_) ,A,7 (City of Miami Beach Board/Committee Member).
Produced ID �L l'/ "may<� I%�"�
Form of Identification
e�so I Kn �---
(NOTARY SEAL)
Signa ure of ry Public
Name of Notary, Typed, Printed, or Stamped NRYgs Charles J. DAgostin
�a NOTARY PUBLIC
-STATE OF FLORIDA
2 Comm# GG 168171
s�NCE 10�� Expires 12/14/2.021
iNA I A N'Vill B E A C I -All
City of Miami each
1700 Convention Center Drive
Miami Beach, Florida 33139
"�y-MLW-hMCb-fl'g-Q-v
OFFICE OF THE CITY CLERK
Email: QQ@rniamibeaqhfI.g_Qv
Telephone: 305.673.7411
P:) >J\ e- r G a'� � L A
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.
7G der:
Male'D
Female
Other
ED I prefer not to answer.
Race/Ethnic Categories:
What is your race?
ED African American/Black
4 ID, Asian or Pacific Islander
CaucasianAtVhite
Native American/American Indian
Other — Print Race:
I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
Yes
NO
I prefer not to answer.
Do you consider yourself Physically Disabled?
es
,,D..--o..,,
ko
ca I prefer not to answer this question.
Page 6 of 6
RNCLERISALUREGWARD AND COMMITTEE APPLICATIONS FINAL DRAFTSWARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
ally v. .... ......
....._..
1700 Convention Center Drive
Miami Beach, Florida 33139
,6 . m ica m ibecLcbd,9-Q—v
OFFICE OF THE CITY CLERK
Email: BC�miamibeachfl.00v
Telephone: 305-673.7411
)A — - COMMITTEE FINANCIAL ACKNOWLEDGEMENT STATEMEIlI
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)
0�s j, F GAWn .. fi --
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.
Q= 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
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
of no more th4R$500, 60 days in jail, or both.
2�9
Signature I Date
Members of the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuant to F.S. §112.3145(1)(a), to file a Statement of Financial Interests (Form 1) with the Miami -Dade County
Supervisor of Elections by 12:00 noon, July 1. Planning Board and Board of Adjustment members who file their
Form 1 with the County Supervisor of Elections automatically satisfy the County's financial disclosure
requirement as a Miami Beach City Board/Committee member and need not file an additional form with the Office
of the City Clerk. However, compliance with the County disclosure requirement does not satisfy the State
requirement.
Page 5 of 6
F:%CLER%$ALLIREGOOARD AND COMMITTEE APPLICATIONS FINAL DRAFTSIBOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
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