Ellen Peterson - 12/31/08
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City of MIami leach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachA.gov
OFFICE OF THE CITY CLERK, Robert Porcher, City Clerk
TEL: (305) 673.7411, FAX: (305) 673.7254
02-14-2007
Ellen Peterson
2560 Sunset Dr
Miami Beach, Florida 33140
~'i~Ml! Youth Center Advisory Board
Congratulations! You have been appointed by Commissioner Richard L. Steinberg
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.
Sincerely,
~~4,10J1o
Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
Ellen Vargas
ATTACHMENTS:
Letter of Appointment
Oath
City Code Ordinance section, applicable to agency, board or committee
City Code Section 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459
Ordinance No. 2006-3543 - Amendment to City Code Section 2-22
Miami-Dade County Code Section 2-11.1 - Conflict of Interest and Code of Ethics Ordinance
City Wide Permit Application - (Parking Department Form)
Booklet - Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employee
We are committed to providing excellent public service and safety '0 01/ who live, work, and ploy in our vibrant, 'ropical, historic community
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city of Miarnl8each, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miomibeochR.gov
OFFICE OF THE CITY CLERK, Robert Porcher, City Clerk
TEL: 1305} 673.7411, FAX: 130S} 673.7254
TO Ellen Peterson
RE: Youth Center Advisory Board
I do solemnly swear or affirm to bear true faith, loyalty and allegiance to the Government of the
United Slates, 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 Slate 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.
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Ellen Peterson
Sworn to and subscribed before me this ~ day of f-e.br"q"J , 200_7
~~~~---=-- ~-
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 Rnancial Disclosure Requirements.
We ore commined 10 providjng excellent public service and safety to 01/ who Jive, work. and play in our vibrant, tropical, histork communify
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MIAMI BEACH
NAME:
Pc. +CY"SD\I'l
Last Name
2-560
BEACH
APPLICATION FORM
E-/ Ie,.,
First Name
F.
Middle Initial
Ml'q.-w' ~ouoh Pc- 3J/'Io
City Slate Zip Code
eh pS'-t....~ Olal. co"'"
Fax Email address
5'-1"1 Y-e,f Dvlve
Street
HOME ADDRESS:
No.
PHONE:
:305 53'l- Lfl..JS5 7'86 271-4<fS'S
Home Work
Business Name:
Position:
Address:
No.
Street
Zip Code
Professional License (describe)
City
State
Expires:
Attach copy uftt,,",, fi,:;:'t!sc
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'llwnershiplinterest for a minimum of six months in a business established in the city.
. Resident of Miami Beach for a minimum of si~ (6) months: Ye~~r No 0
. Demonstrate an ownershiplinterest in a business in Miami Beach for a minimum of six (6) months: Yes 0 or No cV
. Are you a registered voter in Miami Beach: Yes ~ No 0
. (Please check one): I am now a resident of: North Beach 0 South Beach 0 Middle Beach ~
. I am applying for an appointment because I have special abilities, knowledge, experience. Please list below:
....". I ~
."', .
Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that onlv three (3)
choices will be observed bv the Citv Clerk's Office. (Regular Boards of City)
o Art in Public Places Committee
o Beach Preservation Board
o Beautification Committee
o Board of Adjustment.
o Budget Advisory Committee
o Committee on Homeless
o Committee for Quality Education in MB
o Community Development Advisory.
o Community Relations Board
o Convention Center Advisory Board
[] Debarment Committe~
o Design Review Board.
o Disability Access Committee
o Fine Arts Board
o Golf Advisory Committee
o Health AdvisoryCommittee
o Health Facilities Authority Board
o Hispanic Affairs Committee
o Historic Preservation Board.
. Board Required to File State ~isclosure form
o Housing Authority.
o Loan Review Committee.
o Marine Authority.
o Miami Beach Cultural Arts Council
o Miami Beach Commission on Status of Women
o Miami Beach Florida Sister Cities
o Nomnandy Shores Local Gov't Neigh. Improvement
o Oversight Committee for General Obligation Bond
o Parks and Recreation Facilities Board
o Personnel Board.
o Planning Board.
o Police Citizens Relations Committee
o Production Industry Council
o Public Safety Advisory Committee
o Safety Committee
o Transportation and Parking Committee
o Visitor and Convention Authority.
ll'Youth Center Advisory Board
(g~ . ~tt1
F:\CLER\SALL\8&C Applicatlon\B&C Application Revised 091106 iakes.doc
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 Soard: Yes c~o " Years of Service: 3
2. Present participation in Youth Center activities by your children Yesr,(No U. If yes, please list the n~mes of your children, their
ages, and which programs. List below:
Child's name: Lq...."'" Veh,.,....., Age:..!l- Program: c.h~c.f"rd/.-'l.1
Child's name: . ()q'" I ,..1 P-.c h-/)"~ Age: ~ progra";': S 1- '1 c
.Have you ever been convicted of a felony: Yes 0 or No cYlfyes, please explain in detail: .
. Do you currently have a violation(s) of City of Miami Beach codes: Yes 0 or No UY.1f yes, please explain in detail:
. Do you currently owe the City of Miami Beach any money: Yes 0 or No q,/ff yes, explain in detail
. Are you currently serving on any City Boards or Committees: Yes il/or No Q, If yes; which board?
'to-.~ Cc",fe#"" ;kJV"J"'';1
.What organizations in the City of Miami Beach do you currently hold membership in?
Name:
Title:
Name:
Title:
. List all properties owned or have an interest in, which are located within the City of Miami Beach:
rr::J"~<--lC<: (5<:c <;,00",,'" 'l
. I am now employed by the City of Miami Beach: Yes 0 or Nolllfwhich department?
. Pursuant to City Code Section 2-25 (b): Do you have a parent 0, spouse 0, child 0, brother 0, or sister 0 who is employed by the
City of Miami Beach? Check all that apply. Identify the department(s):
This section is "not required" but desired: Age: years old Gender: Male 0 Female []I'"
Ethnic Origin (Check one)
White ii'African-American/Black 0 Hispanic: 0 Asian or Pacific Islander 0 American Indian or Alaskan Native 0
Employment Status: Employed 0 Retired 0 Home-maker 0 Other 0
"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."
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Applicant's Signature
2 -15-07
Date
F- fler.. {>c:fc,rs....,
Name of Applicant (PLEASE PRINT)
Please attach a copy of your resume to this application
NOTE: Applications will remain on file for a period of one (1) calendar year.
Entered By
Date
Received in City Clerk's Office by l~
Name of Oeputy ~ '
Document Control Number (Assigned by the City Clerk's Office) ~
Oate
2
F:\CLER\SALL\R&C Application\H&C Application RevisBd 091106 jakes.doc