James Orlowsky 12/31/23MIAM
APPOINTEE:
BOARD AND COMMITTEE CHECKLIST
DATE OF APPOINTIVIENT;
BOARD/COMMITTEE:Appointed by:
FOR SCANNER
Scan o
Scan o
Scan o
Scan o
Scan o
Processed on:
Scanned on:
TERM END:TERM LIMIT:
FOR CLERK STAFF
o Letter of Appointment
o Letter of Reappointment
o Copy of Letter of Appointment/Reappointmenl e-mailed to Committee Liaison on
)o Board and Committee Application (Completed on
o Resume/Curriculum Vitae
0 Diversity Statistics Reporting (Completed on
o Oath
.)
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
y 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)
^ 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
O DIVERSITY STATISTICS REPOR^^ Keep COPY in file and ORIGINAL for Annual Report.
Received on: I H I Signed by X
Date Bfiwd or Committee Member
Date
.By Employee:
_By Employee:
City Clerk's Office Staff Initials
Date City Clerk's Office 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:\CLER\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
We Ofe comm/ffed to providing excellent public service and safely to all who live. work, and play in our vibrant, tropical, historic community.
James Orlowsky 12/20/2021
Committee for Quality Education Comm. Fernandez
12/31/23 12/31/29
Received January 25, 2022
Office of the City Clerk
12/20/2021 12/5/2021
1/25/2022
1/25/2022
1/26/2022
I
city of Miami Beach, 1700 Convention Center Drive, Beach, Florida 33139 www.miamibeQchfl.Qov
OFFICE OF THE CriY CLERK, RofoBf E. Gronado, City Clerk
Tel: 305.673.7al 1. Fox: 305.673.7254
Email: CityClerk@miamibeoclifl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. James Orlowsky
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: 12/31/2023.
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 Miaml-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.
Mr. James Orlowsky
Sworn to and subscribed before me this day of,2022
Charles D'AgostIn
Deputy Clerk
*Please visit the City of Miami Beach website at www.mlamibeachfl.gov under City Clerk/Board and
Committees for additional information regarding the Financial Disclosure Requirements.
25th Jan
MIA\IBEACH
City o f Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
Received January 25, 2022
Office of the City Clerk
AFFID AVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
S T A T E O F F L O R ID A
C O U N T Y O F M IA M I-D A D E
I a m in co m p lia n ce w ith th e affi lia tio n re q u ire m e n t of Miami Beach City Code Sections 2-22 (4), as (check
(/) all th a t a p p ly):
"fi{ I a m a re sid e n t o f th e C ity o f M ia m i B e a ch fo r six m o nth s o r lo n g e r.
H om e A d dr e ss 1 15A0 AU t 1I IAPT AH 33137
Ff- I ha ve an o w n e rsh ip in te re st (fo r a m in im u m o f six m o n th s) in a b u sin e ss e sta b lish e d in th e C ity of
M ia m i B e a ch (fo r a m in im u m o f six m o n th s).
N am e of B u sin e ss JA ) 9Ro[k Y p0A
B u sin e ss A d d re ss Ei Zu4 LA+1 6,f73/12
j
o I a m a fu ll-tim e e m p lo ye e o f a b u sin e ss (fo r a m in im u m o f six months) and I am based in an office or
oth e r lo ca tio n of th e b u sin e ss th a t is p h ysica lly lo ca te d in M ia m i B e a ch (fo r a m in im u m of six m o n th s).
N a m e o f B u sin e ss _
B u sin e ss A d d re ss ------------------------
"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.
U n d e r pe n a ltie s o f pe rju ry , I de cl a re th a t I ha ve re a d t e fo re g o in g d o cu m e n t a n d th a t th e fa cts sta te d in it
a re tr~ L]il-z
oatun/ D at e
JA€f oto»Ff
P rin te d N a m e
N O T A R Y
S w or n to (o r a ffi rm e d ) a n d sub s cr ibe d be for e m e , by m e an s of a phy sic a l pre sen ce or online no tar iza tion ,
th is 4th d a y o f January , 20 22 b y _
(l y o f M ia m i B e a ch B o ar d /C om m itt e e M em b e r).
FL. Drivers License X P ro d u ce d ID
F o rm o f Id e n tifi ca tio n
Br $on ally Kn own
ala ?'qet,
., CHARLES J. DAGOSTIN êj %$e, w cowu ss o 16s os
%j,J9i&,& eRes:. sano»r 14,205
"·Sy5$ Boded Tru Notary Pubi c Underwrit ers
(N O T A R Y S E A L )
S ig n a tu re o f N o ta ry P u b lic
Charles J. D'Agostin
N a m e o f N o ta ry , T yp e d , P rin te d , o r S ta m p e d
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeactifl.aov
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
□ Female
Q Other
□ I prefer not to answer.
Race/Ethnic Categories:
What Is your race?
□ African American/Black
Q Asian or Pacific Islander
m Caucasian/White
Q Native American/American Indian
Q Other - Print Race:
Q I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
[SlYes
Ono
Q I prefer not to answer.
Do you consider yourself Physically Disabled?
Q Yes
El NoQ 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
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeactifl.aov
Telephone: 305.673.7411
BOARD & COIVIMITTEE 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 Julv 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.
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 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 go-BiQre than $500, 60 days in jail, or both.
Date
nn 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
A f
PARKING
CITYWIDE (CW) BOARD & COMMITTEES
City of Miami Beach, PARKtNG DEPARTMENT PARK! NO APPLICATION
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 gale opens. You may need
to try the other side of the card. Please ensure you hold the entire surface of the cord 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: -JA/^c f M
Board/Committee Name:
Address:
E-Mail Address:
Work Phone:Home Phone
Cell Phone:Preferred Contact Method:t
Vehicle Information
Tog:/5/MT\/0 Color:
State:rc Year:I.0X I
Make:Model:£ C t/f ^^<5
Applicant Signature:
Please provide signed form \o^ Parking Department located at 1755 Meridian Avenue, 2""^ floor. Working
hours are 8:30 to 5:00 p.m. or email to: ParkingReception@miamibeachfl.qov
e-mail subject: BOARD & COMMIHEE PARKING APPLICATION - APPLICANT NAME
Parking Department Section
PERMIT SYSTEM GARAGE ACCESS
Expirotion Dote:ID Card Serial #:
Issued By Prinf Nome:Print Name;
Signature:Signature:
Dote Issued:Date Completed:
form upoctea v/^o/^iJi/^^p'7^Tmo'^TOr\fornis\cn' ooordSJcomSiiffeos porftng^fnTSS^
MIAMIDADE
Clear From Print Form
SOURCE OF INCOME STATEMENT
Section 2-11.1(1) of the County Ethics Code requires that certain employees and public officials file a financial disclosure Statement on a yearly basis by July 1st
of every year.
Disclosure for Tax Year Ending
2020
Last Name
0/l KY
First Name Middle Name/initial
Mailing Address - Street Number, Street Name, or P.O. Box
City, State, Zip
If your home address is your mailing address, and your home address is exempt from public records pursuant to Fla. Stat. §119.07, read
instructions on the following page and check
Filing as an Employee (check one)
□ County |~| Public Health Trust H Municipal:
(Municipality)
Department
Position or Title Employee ID Number
Work address Work telephone Employment began on/ended on
Filing as a Board Member (check one)
ncountv PgMuniciDal: ATAAir
(Municipality)
Board where serving
CoMa-JT\(z^ ^ C/^ r J 0
Alternate address (If home address is exempt)Work telephone Term began on/ended on
ZOZ-Z.
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 ofincome in descending order, with the largest source first, Examples of sources of income include: compensation for services, income from business, gains fromproperty dealings, interest, rents, dividends, pensions, IRA distributions, and social security payments. Also, include any source of income received by anotherperson for your benefit. However, the income of your spouse or any business partner need not be disclosed. If continued on a separate sheet, check here. Q
Name of Source of Income Address Description of the Principal Business Activity
/iLcY
/o r 1 1 X/Tf/?E>T
I hereby swear (or affirm) that the information above is a true and correct statement.
Signatd^f Person Disclosing
I Is KotT.
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
□ Hardcopy
□ Electronic Copy
REMEMBER TO PRINT, SIGN, AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL OR HARDCOPY.
X
Received January 25, 2022Office of the City Clerk