Glendon Hall 12/31/23MI AMWI BEA CH
A P P O IN T E E :
B O A R D /C O M M ITT E E :
FOR SCANNER
Scan o
Scan o
, BOARD AND COMMITTEE CHECKLIST /
rle lo o l/Al_o»re orrore.//2o/2o0-
A Aneen«o» CH) C,ss7o/
roo3/2/1 /
#
Scan o
Scan o
Scan o
FOR CLERK STAFF
o Letter of Appointment
o Letter of Reap ointment
-»r, 9,", 9)y3""vessent
o ford an@ d 'i6ícation (completed on,
en@ c ri 2 ]]/90). o Diversity Statistics Reporting (Completed on 4 U ''
o )ath y y y t
e-mailed to Committee Liaison on
RECEIVED
FEB 12022
C ITY O F M IA M I B E A C H
OFFICE OF TH E CITY CL ER K
Scan o
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)
✓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
o Source of Income Statement
Scan o o Acknowledgment of Financial Disclosure Requirement
I O DIVERSITY STATISTICS REPORTING Keep COPY in file and ORIGINAL for Annual Report.
Recove@o.. y3y/@2 sorea»X "
/
Da7 ~~~-ittre!J=:--7"~e --
roce.sea o:.2y_/ 9o?y en oree: t=... P9t e
Scanned on: d- I j I )..oc} d- By Employee: ------~--::-:--:-::""'=":r----"..::::...-------
• Date
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:ICLER\BOARD AND COMMITT IES DATABASE\CHECKLIST MASTERIB&C Checklist 2015 MASTER.dccx
We are committed to providing excellent pubic service and sal ey to all who lve, wok, ond play in our vibrant, topi cal, hustoic comnmuniNy.
M IA M I BEACH
City o f Miami B e a ch , I/OO Corvonlion Conlon Divo, Momt Boach, Hoda 33 139 yywIlamIbgachll gov
OFFICE OF IHE CITY CIERK, Ralool E. Granado, Cly Clork
Tel: 305.673.7411, Fax. 305.673.7254
Emal l:. Ci lyCl oiko la mtbooch ll.g ov
O a th of O ffi ce
O a th of C iv ility
a n d
A c k n ow le d ge m e nts
TO: Mr. Glendon Hall
RE: Black Affairs Advisory Committee
I do solemnly swear or affirm to bear true faith, loyalty and allegiance lo 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 lo 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.
5an niai
Sworn to and subscribed before me thl
'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.
e"8 ,nt
+o .O} ..1#if%1BEACH
o'of F" City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florid 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
Florida u9A
AFFIDAVIT OF AFFILI ATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
(/) all that apply):
1 am a resident of the City of Miami Bgach for six months of longer.
oe o., S 7 '/8 Pelee_Lru ,1ß,y 33/o
" TT7
o 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).
[[arme t[ [y[[PeSi
[[J [m e s, J(]]f@Sb3
o 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).
[pomm [ P1y[meS,5
HJ[fess J(]]feSS-
"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 it " $2 //ese
Signature Date /
6too) th4v
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of u physical presence oronline notarization
·-3/0«oe122». 6le3 doy HA/
Produced ID
(City of Miami Beach Board/Commjttee Member).
l ve·S lise ama1""$
\
kg., CHARLE S J. DAGOSTIN
s$"" w coMMIsSION # HH 165705 iw ; ; nae-am ha r 14, 2025 ¿i, is$ EXPIRES: December +,
8¿, Bonded Tru Notary Public Underwriters
SEAL)
M IA M I BEACH
City o f M ia m i Be a ch
1700 Convention Center Drive
Miami Beach, Florido 33139
wow.miamibeachll.gov
OFFICE OF THE CITY CLERK
Email:. C @m i am i be achfl_goy
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)
6tr4ooJ p
Last Nam e First Name Middle Initial
I unders tand th at no later th an July 1,_of each year all m emb er s of Board s and Committees of th e City of Mi am i
Beach, including those of a purely advisory nature, are required to comply with Miam i-Dade County Financial
Disclosure Requirem ents.
One of the follo wi ng form s must_be filed with th e City Clerk of Mi am i Beach , 1700 Conv enti on Cen ter Drive,
M iam i Beach, Florida, no later th an 12:00 noon of July 1, of each year:
1. A "Source of Inc om e Statem en t;" or
2. A "Statem ent of Financial Interests (Form 1)';" or
3. A Copy of your latest Federal Incom e Tax Return .
Failure to file one of these fo rm s, pursuant to the Miam i-Dade County Code, may subject the person to a fine
of no m ore than $50 60 days in jail, or both. 1/ ! l3/222
Signature Date / '
1 M em bers of the Planning Board and Board of Adjustment will be notified dire ctly by the State of Florida,
pursuant to F.S . §112.3145(1 )(a), to file a Statem ent of Financial Interests (Form 1) with the Miami-Dade County
Supervisor of Elections by 12:00 noon, July 1. Plan nin g Board and Board of Adjustm ent m em bers who file their
Form 1 with the County Superv isor of Elections automatically satisfy the County's financial disclosure
requirem ent as a M iam i Beach City Board/Com m ittee m ember and need not file an additional form with the Office
of the City Clerk. However, com pliance with the County disclosure requirem ent does not satisfy the State
requirem ent.
Page 5 of 6
F AC LERI SAL LR EGB OAR D AND COM MI T TEE APPLIC ATI ON S FINAL DRA F TSB OARD AN D COMM IT TEE APPL ICATION RE G FINAL.doc
Updated: June 2020
iterereswenev e r se arsero.neoroeserrerereromee
MIAM/BEACH
City of Miami Beach
1700 Convention Conter Drive
Miami Beach, Florido 33139
wow.miamibeachll.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305,673.7411
DIVERSITY STATISTICS REPORT
p
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:
cíe
O Female
0 oner
O I prefer not to answer.
Race/Ethnic Categories:
Wh at,i s your race?
Lu/African Am erican/Black
O Asian or Pacific Islander
O Caucasian/White
O Native American/American Indian O Other- Print Race: _
O I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
9z
13'1 ;refer not to answer.
Do you consider yourself Physically Disabled?
lys
No
O I prefer not to answer this question.
Page 6 of6 »
F:ICLERISALLIREGIBOARD AND COMM ITT EE APPLI CATIONS FINAL DRA FT SIBOARD AND COMMITT EE APPLICATI ON REG FIN AL .docx
Updated: Jun e 2020
M IA M l·DAD E.
EII 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
0( every year.
Disclosure for Tax Year Ending ¡Last Name
2021 H-
Mailing Address - Street Numb er, Street Name, or P,0, Box ,+ ?od«e
First Name
e4o/
Middle Name/initial
~
City, State, Zip
yità ¡evtl £
lf 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 here.[]
Filing as an Employee (check one)
O County O Public Health Trust [] Municipal:
Department
(Municipality)
Position or Title Employee ID Number
Work address I Work telephone Employment began on/ended on
Filing as a Board Member (check one)
O County [] Municiat:
(Municipality)
Board where serving
Alternate address (if home address is exempt)
!
Work telephone Term began on/ended on
701 321 Y 2
List below every source of income you received, along with the address and the principal activity of each source. Include your public salary. Piace 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 separate sheet, check here.O
Name of Source of Income Address Description of the Principat Business Activity
I hereby swear (or affirm) that the information above is a true and correct statement.
2 r dJ·-
' V ..,. Signature of Person Disclosing
///y.22
Date signed \
wcwvo or asps PP"fy
J Hardcopy HEUL!V
[ ] Electronic Copy
FEB 1 2022
CITY OF MIAMI BEACH
r-rrE (r:Tur: (rry(yr.p
OFFICE USE ONLY Accepted: Y I N Deficiency. Processed Date/initials: Scanned Date/lnltials:
138_SP-14 COE 2016
M IA M I BEACH CITYWIDE (CW) BOARD & COMMITTEES
c y cot toot sad, PARKING PARMNr PARKING APPL[CAT[ON
1755 Meridion Avenue, Site 200/Miami Beoch, FL 33139/Ph (305) 6737505 r (305) 673.7000 e4 6200
a
PARKING
A citywide (CW ) parking permit is honored at metered parking spaces and restricted residential zones
parking spaces. A CW parking permit IS N O T honored in prohibited oreas. An Access Cord will be
provided lo you for City Hall Garage (G7) access.
IM P O R TA N T N O TE: Your vehicle license piote serves as your "parking permit". In order to ovoid
any unnecessary enforcement actions, it is importan! that our records reflect the most current and
accurate information regarding your vehicle license plate. Inaccurate and/or outdated vehicle
information may lead lo the issuance of parking citotion(s) and/or the towing of your vehicle.
Please note thai this new access cord C A N N O T be hole-punched or perforated in any manner. To use
the new cord please hold the cord al 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.
A C K N O W LED G EM EN T: I a ck n o w le d g e th a t sh o u ld m y a cce ss card b e lo st, sto le n or
d a m a g e , I w ill b e re sp o n sib le to p ay a $10 .0 0 rep l a cem en t fee .
B o a rd M e m b e r In fo rm a tio n
Date of Application: //31/2022
Applicant Name: to ) Ht
Board/Committee Name: B }ß MO A4
Address: $7 ¥8 p Nshts bei -h
E-Mail Address: ooH#@ 6MAi_. ov_
Work Phone: 30 331 (0 2 Home Phone
Cell Phone: Preferred Contact Method:
V er ic e n o rm a tio n î
Tag: D P \J1 5 Color: ,4el t;.
State: t Year: 20 o 8
Make: B rt w) Model: 5 .
Ap plicant Sianature: 6 '
Please provide signed form to the Parking Department located ot 1755 Meridian Avenue, 2" floor. Working
hours are 8:30 to 5:00 p.m. or email to: Pa rk in g R ece pti o n@m ia m ib ea ch fl ,g ov
e-m a il su b ject : BO AR D & C O M MI TTE E PA R K IN G A P PLI C A T IO N - A P PLI C A N T N A M E
hi l tuf
P. ki D ar una epartment ection
PERMIT SYSTEM GARAGE ACCESS
Expiration Dote: ID Cord Serial #:
lssued By Print Name. Print Name:
Signature. Signalure.
Date lssued: Dote Completed:
s