James OrlowskyM IAM I B E A C H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
OFFICE OF THE CITY CLERK
Em ail: BC@m iam i beach fl.gov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH AND THE COMMITTEE
FOR QUALITY EDUCATION IN MIAMI BEACH
As a voting member of the Committee for Quality Education in Miami Beach, I am in
compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4) and
2-19 0.13 7 as:
~ I am a City of Miami Beach resident for six months or longer.
Home Address: 9 IS L A N D A V E N U E A P T 14 14 M IA M I B E A C H , FL 33139
[E}1am the parent/guardian of a student attending a Miami Beach school for +# Z3-2+ .pool
year.
School: NAUTILUS MIDDLE SCHOOL, MIAMI BEACH SENIOR HIGH SCHOOL
Under penalties of perjury, I declare that I have read the foregoing document and that the facts
tated in it are true.
' .@ or.owsks
JANUARY 12, 2024
Date
Printed Name
MIAMI
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Em ail: BC@miamibeachf._gov
Telephon e: 305.673.7411
RECEIVED
JAN 17 2024
CITY OF MIAMI BEACH
OFFICE OF /FE CIT CLEnk
AFFIDAVIT OF AFFILI ATION W ITH THE CITY OF MIAMI BEACH
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (/) all that apply):
}/[1am a resident of the Ci t y of Mia mi Beach for six months or longer.
Horne Address: 9 ISLAND AVENUE APT 1414 MIAMI BEACH, FL 33139
}/{1have 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).
Name of Business: JAMES ORLOWSKY CPA
Business Address 4014 CHASE AVENUE SUITE 214 MIAMI BEACH, FL 33140
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 th at is physically located in Miami Beach (for a
minimum of six months).
Name of Business: _
[[AS[[]eSSS \(SH[eSS,
"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 are true.
)a/or
Date
O w ~y
Printed Name