Dina Dissen 12/31/2008I•
City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Fbrida 33139, www.miarnibeachfl.gov
OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk
TEL: (305) 673-741 1, FAX: (305j 673-7254
07-24-2007
Dina Dissen
2474 Praire Ave
Miami Beach, Florida 33140
1BJECT: Police Citizens Relations Committee
Congratulations! You have been appointed by Commissioner Jerry Libbin
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 1st, 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,
~~
Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
Acting Chief Carlos Noriega
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 ore commined to providing excellent public service and safety to all who live, work, and play in our vibrant, hopical, historic community
I•
City of Miami Bsath, 1700 Convention Center Drive, Miami Beach, Fbrida 33139, www.miamibeachfl.gov
OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk
TEL: (305) 673-7411, FAX: (305) 673-7254
TO Dina Dissen
RE: Police Citizens Relations 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: 12/31/2008.
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 theF/orida Commission on Ethics Guide to the Sunshine
Amendment and Code of Ethics for Public Ohicers 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 1st, following the closing of the calendar year on which I have served.
t
tna Di
Sworn to and subscribed before me thi day o ~ , 200_)
-~~ _
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.
We ore committed to providing excellent public service and safely to all who live, work, and play in our vibrant, tropical, historic community
CITY OF MIAMI BEACH BOARDS AND COMMITTEE
APPLICATION FORM
Pursuant to City Code section 2-22(4) a and b: Members of agencies, boards, and committees shall be affiliated with the city; tt
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
an individual shall demonstrate ownership/interest for a minimum of six months a business established in the city,
C~
Business Name: 1~' Q Applicant's Position:
Address:
No. Street 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 [ ]
I am applying for a Board appointment because I have special abili ' s, knowledge, experience: Yes [ ]
My special abilities, knowledge, or experience is:
Are you a registered voter in Miami Beach: Yes [ ] or No [
NAME: ~~(1y ~~~CC, _Yl C~
Last Name y ~ Fi st Name Middle Initial
Home _,~ ~'' ~~~~~ ~~ ~ ~ Ur^(1• ~ r ~ ~~ 1~'IG
Address: No. Street (~~ ~ City State Zip Code
Phon~~J~~LJ ~~1._~~~~. SO~U`n~ i 0~' ~""1 l.,i ~fliJ~ ti.`~~'~ ~CJ~"1t~~'CCi~'Yl
Home Work Fax Email address
I am now a resident of: North Beach [ ]South Beach [ ]Middle Beach [~~
[ ]Owner [ ]Stockholder/Shareholder [ ]Corporate Officer [ ]Other Explain:
Professional License (describe):
Attach a co ofthe /i e e /" t d b
State Zip Code
Expires:
py c ns is e a ove.
1. Have you ever been convicted of a felony: Yes [ ] or No f yes, please explain in detail:
z. Do you currently have a violation(s) of City of Miami Beach codes: Yes [ ] or No If yes, please explain in detail:
3. Do you currently owe the City of Miami Beach any money: Yes [ ] or No [~..~
If yes, explain in detail:
4. Are you currently servin on any Cif~( Boards or Committees: Yes [ ~ or No
If yes; which board? ~e?s~`;t~,~dl 1~~~}-~-~~ccx}~~~r~ tUm~~:r-,, Ju~y 1
What organizat~ion/sj~in the City of Miami Beach do you currently hold membership in?
Name: Iv t ~ Title:
Name: 1 v ~ Title:
List all properties owned or have an interest in, which are located within the City of Miami Beach:
}. ~ t ~- ~-t P>t:,~,a c ~~e
I am now employed by the City of Miami Beach: Yes [ ] or No If yes, which department.
Pursuant to City Code Section 2-25 (b): Do you have a parent [ ], spouse [ ], child [ ], brother [ ], or sister [ ]who
Is employed by the City of Miami Beach? Check all that apply. Identify the department(s):
Please list your preferences in order of ranking [i] first choice [Z] second choice, and [3] third choice. piease~note tl
only 3 choices will be observed by the City Clerk's Office.
(Regular Boards of City) (*Board Required to File State Disclosure form)
] Art in Public Places
] Audit Committee
] Barrier Free Environment Committee
Beach Preservation Board
] Beautification Committee
] Board of Adjustment (Flood Mgmt.)*
] Budget Advisory Committee
] Committee on Homeless
] Committee for Quality Education in MB
] Community Development Advisory*
] Community Relations Board
] Convention Center Advisory Board `
] Convention Center Capital Projects Oversight
] Debarment Committee
Design Review Board*
] Fine Arts Board
] Golf Advisory Committee
] Health Advisory Committee
] Health Facilities Authority
J Hispanic Affairs Committee
] Historic Preservation Board*
J Housing Authority*
] Loan Review Committee*
[ ]Marine Authority*
[ ]Miami Beach Cultural Arts Council
[ ]Miami Beach Commission on Status of Women
( ]Miami Beach Florida Sister Cities
[ )Normandy Shores Local Gov't Neighborhood Improvement
[ ] Nort Beach Youth Center Oversight Committee
[ ] lance Abatement Board*
[ versight Committee for General Obligation Bond
[ ] P rks Recreation Facilities Board
[ ] er nnel Board*
P nning Board*
_~ olice Citizens Relations Commitf.~t'~
] Production Industry Council
]Public Safety Advisory Committee
]Safety Committee
] Transportation and Parking Board
] Visitor and Convention Authority*
] Youth Center Advisory Board
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 [ ] No [ ] (Years of Service [ ]
2. Present participation in Youth Center activities by your children Yes [ ] No [ ]. If yes, please list the names of you
children, their ages, and which programs. List below.
Child's name:
Child's name:
Age: Program:
Age: Program:
This section ' "not required" but desirert. Age: [ J Gender: M ~'~
Ethnic Ori (Check one)
White [ ) African-American/Black [ ] Hispanic: [ ]
Asian or Pacific Islander [ ]American Indian or Alaskan Native
Employment Status: Employed [ ] Retired [ ]Home-maker [Other [
orF(~CJ~
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
Me ers." -.
Applicant's Signature Date Name of Applicant (PLEASE PRINT)
Attachment: Please att
NOTE: Appli dopp ill r,
Received in City Clerk's Office ~/U~
Document Control Number (Assigned by the City
~y of your resume to your application.
file for a period of one (1) calendar year.
Clerk
Office) ~~
Rev # 7- 01/08/04