Mojdeh Khaghan 12/31/2008
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk
Tel: (305) 673-7411, Fax: (305) 673-7254
12/21 /2007
Mojdeh Khaghan
5151 Collins Ave
Miami Beach, Florida 33140
SUBJECT; Youth Center Advisory Board
Congratulations! You have been reappointed by Commissioner Ed Tobin
to the above referenced agency, board or committee for a term ending: 12/31/2008.
If you are unable to accept this appointment, please notify the City Clerk's Office at
(305) 673-7411.
Please read the enclosed material carefully. Again, congratulations and good luck.
Sincerely,
~er:f ~~ ~~~~:x - y .
~~
Robert Parcher 'f
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, 2-2458, 2-459
Ordinance 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
Employees
We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community.
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.oov
OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk
Tel: (305) 673-7411, Fax: (305) 673-7254
TO Mojdeh Khaghar~
RE: Youth Center Advisory Board
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 ~cers 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.
Mojdeh Khag air -'1
Sworn to and subscribed before me this day of , 20
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.
We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community.
W
NAME: ~ 1~ L1 [~-U~~l 1"l ~'~~-I
Last Name First Name Middle Initial
HOME ADDRESS:
No.
PHONE:
Home
Business Name:
Address:
No.
Professional License (describe) _
Email address
City State Zip Code
_ Expires:
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 foram' imum of six months in a business established in the city.
• Resident of Miami Beach for a minimum of six (6) month Yes or No
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes or No
• Are you a registered voter in Miami Bea : Ye or No
• (Please check one): I am now a resident o :North Beach South Beach fiddle Beac
• I am applying for an appointment because I have special abilities, knowledge, experience. Please list below:
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 Citv Clerk's Office. (Regular Boards of City)
Art in Public Places Committee
Beach Preservation Board
Beautification Committee
Board of Adjustment"
Budget Advisory Committee
Committee on Homeless
Committee for Quality Education in MB
~` Community Development Advisory"
Community Relations Board
Convention Center Advisory Board
-~ Debarment Committee
Design Review Board"
Disability Access Committee
Fine Arts Board
Golf Advisory Committee
Health Advisory Committee
CC Health Facilities Authority Board
Hispanic Affairs Committee
Historic Preservation Board'
"Board Required to File State Disclosure form
Street
Fax
Position:
Street i
Housing Authority"
Loan Review Committee'
~~ Marine Authority*
Miami Beach Cultural Arts Council
_: Miami Beach Commission for Women
Miami Beach Florida Sister Cities
Normandy Shores Local Gov't Neigh. Improvement
Oversight Committee for General Obligation Bond
Parks and Recreation Facilities Board
_ Personnel Board"
Planning Board"
Police Citizens Relations Committee
Production Industry Council
Public Safety Advisory Committee
Safety Committee
Transportation and Parking Committee
Vim' itor and Convention Authority*
'Youth Center Advisory Board
State Zip Code
City
1
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E~O,~RD ADD ~C7t~l"~'EE ~I~PICA~"IOd C3R!
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 (ti) months: Yes~or No :-
I am applying for a Board appointment because I h ve special abilities, knowledge,,experience: Yes'
My special abilities, knowledge, or experience is: ~~-.CGt.~1Q b DaCTIP~.4FUCQ.. ~-~ ~~t
Are you a registered voter in Miami Beach: Yes }~ or I o
NAME: ~ ~p1v~1-FAfJ f`~l(~~(~'1-F
Last Name First Name Middle Initial
Home:
Address: 5 (~ I ~~ (a .t -J S PN~r.)u t/ I_l.l 1 ArM I (~EAG F-~ . ~L ?~31 ~}-D
No. Street City tate Zip Code
Phone: ,~ (7 S
Home
- SZt ~-- 8~4.8~{- ~~- S'b~-oo4~ rrI KCmo/gar)r
Fax Email address
(Please check one}: 1 am now a resident of: North Beach _ South Beac:l~ ~~ lyllddle Beach
Business Name: ~ ~jX~l~ l l1i' (SS ~.l~G Applicant's Position: V I ~ 17 i?~S t 1~rJ ~
Address: C,. l S I COLI.! 1~S ~11/E . ICI (P-'n-'~ l ~~l^} ~C~ 3~J (i'I"~
No. Street City State Zip Code
Owner Stockholder/Shareholder~Corporate Officer - Other Explain:
Professional License (describe) I1itQ.lM.~ lrlJ ~1DOd S1 Wvl~4~ ice(. ~ ~y ~/S Expi
.t4f~ch a ;:~sz:.b' es:~ ff?c~ ;ic~r~cs la~tec! afrove.
1. Have you ever been convicted of a felony: Yes .~ or No~ If yes, please explain in
2. Do you currently have a violation(s) of City of Miami Beach codes: Yes _' or No~. If yes, please explain in
3. Do you currently owe the City of Miami Beach any money: Yes - or No~ If yes, explain in detail
4. Are you currently serving on any City Boards or Committees: Yes -' or No~ If yes; which board?
What organizations in the City of Miami Beach do you currently hold membership in?
Name: //~~~~
-Ill-C1d~~~,l,-~lis SC.C. Title: lilil~Ct.t.GX1.~) ~-~~•~/
Name:
List all properties owned or have an interest in, which are located within the City of Miami Beach: ~i 1 3 ~ ~,Sr~ L~.~l 1~ ~/~Il.) L( ~
GO~'D oM ~ ~ t tl~ W ~.~ I R-E-~>I ~ r'~y'D M ~~ ~~ l ~ ~ o .+-r-t cal
I am now employed by the City of Miami Beach: Yes .. ! or No~ If yes, which department?
Title:
.eow
Pursuant to City Code Section 2-25 (b-: Do you have a parent , spouse C, child -', brother G, 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 [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
_' Beach Preservation Board
Beautification Committee
Board of Adjustment*
Budget Advisory Committee
Committee on Homeless
~~ Committee for Quality Education in MB
Community Development Advisory*
Community Relations Board
l 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 Board
,,Historic Preservation Board*
*Board Required to File State Disclosure form
C 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 Neigh. Improvement
-~ Oversight Committee for General Obligation Bond
^; Parks and Recreation Facilities Board
Personnel Board*
Z.Planning Board*
Police Citizens Relations Committee
Production Industry Council
Public Safety Advisory Committee
Safety Committee
~~ Transportation and Parking Committee
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: ~U~t/ rl. ~ ~~otn laG1P.,r 'Dn~v-h~i!Jn~r. i-n, 'I~YOS(YQNKS Q7t''~a roW ~1B'l~{'~.t .. GU.cc~ ~a.u...i~~Q. ~~ ~'~~-~S.
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 your children, their ages,
and which programs. List below:
Child's name: ,1 n S l~ru A ~ Ate 1 Prt._ Age: _ ~' Program: ~ t3'~ ~ ~s ~.kbc~ ~ L
Child's name: f~l-~'!~'1~ ~1 /~-itJ i P(I~ Age: ~_ Program
This section is "not required" but desired: Age: ~ years old
Ethnic Origin (Check one)
White African-American/Black ^C Hispanic: '.-
Asian or Pacific Islander -American Indian or Alaskan Native
Employment Status: Employed;~,'Retired -' Home-maker ~= Other ~ _
"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."
C~~~J~ ~------~ ~ i 2~i c)(o l~l E~~`D~I-- L . ~ ~~A C-fN Al ~
Applicant's Si ature Date 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 __~ by G., ~ (~~~ Deputy Clerk Date
Document Control Number (Assigned by the City Clerk's Office) Entered By Date 6
Revised 9/11/06 Ih
Gender: Male ~ Females!
~~~ I~61