Laurence Moser 12/31/23l8BEACH
BOARD AND COMMITTEE CHECKLIST
aeonre. LAI NE Hog__ owreorarereoomrwer._//9Z/22
oocowwre±e._.óSy O/A±pyiy04boca o».. Coca_KA4SoU
oRscAwe ro aer so Coile4j ))a f)/3, /)9
scan o o Letter t Appointment TERM END:}/ .__rERM Lurr: Le_, ó _ /
Scan o o Letter of Reappointment ' )9OP0f,-9fer, 0/, Appointment/Reappointment
scans Sela#álc'peaon completed on4/ L >
Scan o o Résumé/Curriculum Vitae
o Diversity Statistics Reporting (Completed on_z NL
o Oath
on
Scan o
RECEIVED
3 2022 FEB
IMPORTANT INFORMATION FOR BOARD AND COMMITT EE 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 OIT OF MIAMI BEACH
rFICE OF THE CITY CLERK
o Citywide Permit Application (Parking Department Form)
Scan o
Scan o
Received on:
o Booklet - Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
o Source of Income Statement
o Acknowledgment of Financial Disclosure Requirement
o DIVERSITY ST A TISTICS REPORT Keep COPY In file and
8[}_30 0ò _sanea»y h_ RAM-" ' O
. Date
Processa._2/2/ )0_)_e eneo»ee: .a5.ad... s.a..
9-7 _3 7 ,J-6?~ Employee __ '----+--h ~---+---::::>"""'~----
Date
Scanned on:
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 DATABASEICHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
• mm mrmmm"mmmTHT
MI A.MIBEACH
City of Miami Beach, I/OO C onven tion Can tor Drive, Miam i Beach, Florid 33 139 wyNy._miam ibea chll.go
OFFICE OF IHE CITY CIERK, Rofool E. Granado, Ciy Clork
Tel: 30 5.6 73.7411, Foc 305.6 73.72 54
Email: CiNylerk,@mlamíbeachill.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Laurence Moser
RE: LGBTQIA+ 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: 12/31/2023.
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 finan cial disclosure requirem ents 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.
kg2cue tor
Mr. Laurence Moser
Sworn to and subscribed before me this 3
7
„
022
P lease 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.
M IA M I BEACH
City of Miami Beach
1700 Convention Center Drive
Miomi Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
RECEIVED
FEB 3 2022
CITY OF MIAMI BEACH
OFF ICE OF THE CITY CLERK
AFFIDAVIT OF AFFILIATION 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 /) 3 that apply):
✓I am a resident of the City of Miami Beach for six months or longer. e.wc. H1€7 h end [\4i Bah, f_33l'/°
Ji 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).
-- #2"r4: or. Ri si! [no ijz±, 3//0
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 Bead, (for a minimum of six months).
[Jaffe tf Py]mess
[1SI[gS (]fesi-
"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 p alties of perjury, I declare that I have read the foregoing document and that the facts stated in it
e! .. 8/0/0002
t%i oset- "
Printed Name
NOTARY
Sworn to (or affirmed), and subscribed before me, by means of o physical presence or Xx6ntine notarization,
.7.Jee1 a2. L A4Ree QSe
(City of Miami Beach Board/C9mmittee Member).
roaoceao ft_.LkeKS_/ en Se
Form of Identification
y Known
L
ii., CHARLES J. DAGOS'TIN 5$" jf; wcoussioivw tss
i,l%da.i$ ExPRts: Decamtvor 14, 2025
"7¥¿$" Bonded Thru Notary Public Underwriters
is
(NOT ARY SEAL)
M IA M l·DAD E . EI SOURCE OF INCOME STATEMENT
Section 2-11.1(@) 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 I Last Name First Name Middle Name/Initial
2021 Moser Laurence E.
Mailing Address - Street Number, Street Name, or P.O. Box
4767 Alton Road
City, State, Zip
Miami Beach, FL 33140
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 here.[l
Fili ng as an Em ployee (chec k one)
D County D Public Health Tru st [] M un i cipal :
(Municipality)
Department
Position or Title Employee ID Number
Work address I Work telephone Employment began on/ended on
FIii ng as a Boa rd M em be r (chec k one )
E] county D M unicipal: City of Miami Beach
(Municipality)
Board where serving
LGBTQIA+ Advisory Committee
Alternate address (if home address is exempt) I Work telephone I Term began on/ended on
(305) 785-1138
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 separate sheet, check here.[]
Name of Source of Income Address Description of the Principal Business Activity
G atew ays Unlim ited, Inc. 4767 A lton Road Pro m otional item s distributor and
Miam i Beach, FL 33140 distribution logistics.
1 hereby swear (or affirm) that the information above is a true and correct statem ent.
.£.Msastre "vs a-\ \0098
oae'ioned
co sY (@ R/NEW9NT
[] Hardcopy "
7e o"von" %%7y 3 2022
C ITY O F M IA M I B E A C H
O FF IC E O F TH E C ITY C LER K
OFFICE USE ONLY Accepted: Y I N Deficiency. Processed Date/Initials: Scanned Date/Initials:
I3p ,Do.q E?(18
' MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
www.miamibeachfl.goy
OFFICE OF THE CITY CLERK
Email: BC @ m iam ibeachfl.gov
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 July1,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.
;;
Qwl 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:
[i;) 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
of no e than $500, 60 days in jail, or both.
fo
Sign Date
' Members of the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuant to F.S. $112.3145(1)(a), to file a Statement of Financial Interests (Form 1) with the Miami-Dade County
Supervisor of Elections by 12:00 noon, July 1. Planning Board and Board of Adjustment members who file their
Form 1 with the County Supervisor of Elections automatically satisfy the County's financial disclosure
requirement as a Miami Beach City Board/Committee member and need not file an additional form with the Office
of the City Clerk. However, compliance with the County disclosure requirement does not satisfy the State
requirement.
Page 5 of6
F:ICLERl$ALLIREGIBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTSIBOARD AND COMMITTEE APPLICATION REG FINAL.dOcx
Updated: June 2020
í
M IAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33 l 39
ww w_miamihegchf[_gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
PIYERSlTY STATISTICS REPORT
[%ose-
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 .
. l Male
O Female
L oner
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
~
. Af · an American/Black
O sian or Pacific Islander
., 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? u
O I prefer not to answer.
Do you consider yourself Physically Disabled?
ef
O I prefer not to answer this question.
Page 6 of 6
F:\CLER1$ALLIREGIBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.dccx
Updated: June 2020
MIAM I BEACH CITYWIDE (CW) BOARD & COMMITTEES r.1111
car otos ras ni@ve oreo«cwor PARKING APPLICATION E.IS
1755 Meridian Avenue, Suite 200/Miami each, FL 33139/Ph: (305) 673.7505 67 (305) 673-7000 ea. 6200 PARKÍjG
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 areas. An Access Card will be
provided to you for City Hall Garage (G7J access.
IMPORTANT N O TE : 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(sl and/or the towing of your vehicle.
Please note that this new access cord CA N N O T 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:
Address: [[
.Mail Address[_Mo6€-@ »Ate)/A im; co
Work Phone: 05 75 113 Home Phone
Cell Phone: Preferred Contact Method: qi
Vehicle Information
tes L7 9 Color: l
see: 'p- Year:
wake: Sh e Model:
Applicant Si4n a ture :f , 5al@
Please provide signed form to the Parking Department located at 1755 Meridian Avenue, 2° 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 Nome:
Si gn a ture: 6 Signature:
Date Issued: Date Completed: