Jacqueline Hertz 12/31/08
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www m:olTlibeochfl gov
OFFICE OF THE CITY CLERK, Robert Porcher, City Clerk
Tel 305~6737 4 I 1, Fox 305~673~7254
01-08-2007
Jaqueline Hertz
565 N. Shore Dr
Miami Beach, Florida 33140
SUBJeCT: Miami Beach Commission on Status of Women
Congratulations! You have been appointed by Commissioner Simon Cruz
to the agency, board or committee named above for a term ending: 12/31/2008.
Pursuant to Ordinance No. 2006-3543, commencing with terms beginning on or after
January 1 st, 2007, the term of board members who are directly appointed by a member of
the City Commission shall automatically expire on December 31 of the year the appointing
elected official leaves office.
If you are unable to accept this appointment or have any questions, please call the City
Clerk's Office at 305-673-7411. Please read the enclosed materials carefully.
Congratulations again and good luck.
Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
Maria E. Martinez
ATTACHMENTS:
1. City Code Ordinance section, applicable to agency, board or committee
2. General Provisions of Ordinance NO.97-3086 Amended by Ordinance No. 2006-3543
3. Ordinance No. 97-3105
4. Citywide parking permit application - Return completed application to the Parking
Department located at Palm Court Building, 309 23rd Street, Suite 200 - Tel: 305-673-7505
5. Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employe
6. Miami Beach Code Section 2-459
7. Miami-Dade County Code Section 2-11.1
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florido 33139, wwwmiamibeachflgov
OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk
Tel. 305~673~7 411 , Fox 305-673~7254
TO Jackie Hertz
RE: MB Commission on the Status of Women
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: 12/31/2008.
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 theFlorida Commission on Ethics Guide to the Sunshine
Amendment and Code of Ethics for Public Officers and Employees, and understand that as a member
of a City of Miami Beach Board and/or Committee, I must comply with the financial disclosure* require-
ments 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.
q2?"'-~;;:~~-
Sworn to and subscribed before me this ~ day of ~n , 20091-
~U~*- -:::.;~
~.__ .____m u_______
Deputy 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.
"ve '~Ire ::u:))!"(~iited i() prclviding excr.:.":<I,,;.'-Ji:
:.(J'';'i,.-P ~-:n(1
to ',..,;ho f:.ve, vv()!k. und plo'y in vibr".:mi, ~ropiCGl, historic community
~
-
MIAlv\1 BEACH
Pursuant to City Code section 2-22(4) a and b: Members of agencies, boards, and committees shall be affiliated with the city; this
requirement shall be fulfilled in the following ways: a) an individual shall have been a resident of the city for a minimum of six months; or
b) an individual shall demonstrate ownership/interest for a minimum of six months in a business established in the city.
Resident of Miami Beach for a minimum of six (6) months: Yes~ or No
Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes ..~ or No [j
I am applying for a Board appointment because I have special abilities, knowledge, experience: Yes~
My special abilities, knowledge, or experience is .:.!: l-h\J-t.. .s~) '7'lt-C- Cc::l",-~ I'W<-. I.)..-to "I~
Are you a registered voter in Miami Beach: Yes ~or No
NAME: H~"'L.
Last N~rpe
Home: S "oS" 1\l.~i\4 S W D;L.C 04.,(.Jf.
:r4<LQv~' A,,)oot.
First Name
s
Middle Initial
Phone:
No.
(~t).r ) l'~t"- '?"'~
Home
Street
~I.~~~
City
I=c...
State
.33c't
Zip Code
Address:
Work
Fax
Email address
(pleES":
. ...../....
;~~.:::~3,i:~ ;;'j ~~,:;)~ir~.;
::'#;';:~2C-! LJ
E..'"ct\ 0
Business Name:
Applicant's Position:
Address:
No.
Street
City
State
Zip Code
DOwner c:: Stockholder/Shareholder 0 Corporate Officer [] Other Explain:
Professional License (describe)
i-lti~:1ch t:.:
Expires:
1. Have you ever been convicted of a felony: Yes C or No~ If yes, please explain in detail:
2. Do you currently have a violation(s) of City of Miami Beach codes: Yes C or No)( If yes, please explain in detail:
3. Do you currently owe the City of Miami Beach any money: Yes [1 or NO)( If yes, explain in detail
4. Are you currently serving on any City Boards or Committees: Yes ~or No O. If yes; which board? l C~ , S t e:..u 0 A..J
~ ~.s 'Z)..t: If....)D''-~
V\lhat organizations in the City of Miami Beach do you currently hold membership in?
Name:
Title:
Name:
Tille:
List all properties owned or have an interest in, which are located within the City of Miami Beach:
J--k-..-t: - S1...r N.OL.li .s(~ ~v' ~
I am now employed by the City of Miami Beach: Yes 0 or N~ If yes, which department?
F:\CLE.H\$.4LL\B&C App!icarOll\t..V~C /..~tpljtd!JOI1 Pe-,.nsed O~J110G_dOG
Pursuant to City Code Section 2-25 (b): Do you have a parent ( spouse
Beach? Check all that apply. Identify the department(s). r{ -A
. child ',brather
ar sister
wha is employed by the City of Miami
Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that only three (3)
choices will be observed by the City Clerk's Office. (Regular Boards of City)
~ Art in Public Places Committee
Barrier Free Environment Committee
[j Beach Preservation Board
[] Beautification Committee
Board of Adjustment*
[1 Budget Advisory Committee
[] Committee on Homeless
o Committee for Quality Education in MB
o Community Development Advisory*
$ Community Relations Board
o Convention Center Advisory Board
'0 Convention Center Capital Projects Oversight
o Debarment Committee
o Design Review Board*
o Fine Arts Board
LJ Golf Advisory Committee
o Health Advisory Committee
o Health Facilities Authority Board
o Historic Preservation Board*
Housing Authority*
Loan Review Committee*
Marine Authority.
Miami Beach Cultural Arts Council
~m~each Commission on Status of Women
Miami Beach Florida Sister CIties
I Normandy Shores Local Gov't Neigh. Improvement
Oversight Committee for General Obligation Bond
Parks and Recreation Facilities Board
I Personnel Board.
I : Planning Board*
,; Police Citizens Relations Committee
Production Industry Council
'; Public Safety Advisory Committee
['l Safety Committee
Transportation and Parking Committee
: Visitor and Convention Authority.
[J Youth Center Advisory Board
<: <:) 5 u....)
*Board Required to File State Disclosure form
Note: If applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth
Center:
1. Past service on the Youth Center Advisory Board: Yes c- No c-; Years of Service:
2. Present participation in Youth Center activities by your children YeSIJ No ~J. If yes, please list the names of your children, their ages,
and which programs. List below:
Child's name: Age: _ Program:
Child's name:
Age: _ Program:
This section is "not required" but desired: Age: _ years old
Ethnic Origin (Check one)
Whlte)tAfrican-American/Black:J Hispanic: [J
Asian or Pacific Islander IJ American Indian or Alaskan Native [J
Employment Status: Employed [J Retired L] Home-maker C Other Li
Gender: Male iJ
Female)1l
"I hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
Article VII- of the City Code "Standards of Conduct for City Officers, Employees and Agency Members."
~'"' I..:.- /. ~
p nt" ignature .
I In IEl
Date
.::TAe.Q.J ~'.c..X. $. L-+~""1..
Name of Applicant (PLEASE PRINT)
Attachment: Please attach a copy of your resume to your application.
NOTE: Applications will remain on file for a period of one (1) calendar year.
Received in City Clerk's Office I {IT 16~bY '-- P ~,~ CJl.sc-::::..~ Deputy Clerk Date
Document Control Number (As~ Clerk's Office) Entered By Date
Revised 9/11/06 Ih
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