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Dushan Koller 123/31/2009~i~t. '~ . 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 12-21-2007 Dushan Koller SUB,IECTr Budget Advisory Committee Congratulations! You have been appointed by Commissioner Jonah M. Wolfson to the agency, board or committee named above for a term ending: 12/31!2009. 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, ~Ll U~~iv~ `~i ~~,.~,.x ~ Robert Parcher City Clerk cc: Saul Frances, Parking Director Jose Cruz 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 to all who live, work and play in our vibrant, tropical, historic community. e t r¢ 1 y ff i J a ' -~ ~~n.~< 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 Dushan Koller RE: Budget Advisory 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: 12/31/2009. 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 Emp/oyees, 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 co mi~tee on which I serve) on July 1st, following the closing of the calendar yea?•~n which I have serve ,/ f l~ Dushan Ko Sworn to and subscribed before me this ~ day of , 200 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. ~~ ~ ~ EAR ~ CITY OF MtAM1 BEACH BOARD AND COMMITTEE APPL{CATION FORM NAME: ~ D L ~ ~ - \ ~ ~~Aii'7'/'T Last Name /jam .~,/ p //First Name ~.J Middle Initial ~L HOME ADDRESS: L~ 0 © ~~ "` ~/ r ~ ^ ' ` ~ ~ ~ , ` ~ ~~ No. ~_ Street City State Zip Code PHONE: ~ ®S- Q (D ~ ~ ~(0 ~ ~ 7~~ ti ~~'j'--~3d' ~ 3®s ~~c~-~7~7r~/~...JR-~'~a7A~. •~De~j Home Work Fax Email address Business Name: Position: Address: No. Street City State Zip Code Professional License (describe) Expires: Attach a copy of the license Pursuant to City Code section 2-22(4) a and b: Members of agehcies, 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 ownershipfinterest 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 2~ • Are you a registered voter in Miami Beach: Yes ~or No • (Please check one): I am now a resident of: North Beach South Beach ~ Middle Beach • I am applying for an appointment because I have special abilities, knowledge, experience. Please list below: ~+~~~~ r N L ~ o ~vn~r ~~ , ~v~ ~~c~S O~~E*~ ~~~ .~o ~.~ifZ~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 ^ Beach Preservation Board ^ Beautification Committee ^ Board of Adjustment* Budget Advisory Committee ^ Committee on Homeless ^ Committee for Quality Education in MB 0 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 ^ Health Facilities Authority Board ^ Hispanic Affairs Committee ^ Historic Preservation Board* * Board Required to File State Disclosure form ^ 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 0 S ,~~ ^ Visitor and Convention Authority`-~~a\ ~ ~ ,~` ^ Youth Center Advisory Board 1 ~~~ ~~ ~' ~w ~~~i~ a~s~Tesopo<ary lnfesnet Files~OLK6701BC Application Revised 102907.doc ~~ , ~L\~ 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 C Years of Service: 2. Present participation in Youth Center activities by your children Yes'"7 No '_7. 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: .Have you ever been convicted of a felony: Yes _~ or No~ If yes, please explain in detail: • Do you currently have a violation(s) of City of Miami Beach codes: Yes ~ or No~ If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money: Yes ^ or No~ If yes, explain in detail • Are you currently serving on any City Boards or Committees: Yes C or No~4 If yes; which board? • What organizations in the City of Miami Beach do you currently hold membership in? Name: Name: Title: Title: • List all properties owned or have an interest in, which are located within the City of Miami Beach: • I am now employed by the City of Miami Beach: Yes ~ or Nq~ Which department? • Pursuant to City Code Section 2-25 (b): Do you have a parent C, spouse C, child ~, brother C, or sister C 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 ~ Female ^ Ethnic Origin (Check one) White,~African-American/Black ^ Hispanic. Asian or Pacific Islander ^ American Indian or Alaskan Native ^ Employment Status: Employed ^ Retired~ome-maker ^ Other ^ _ "I he attest to the accui Artic VI - of the i~~ty/IC,,ode lM/~/ App 'cant' Signature truthfulness of the application and have received, read and will abide by Chapter 2, ~ds of Conduct for City Officers, Employees and Agency Members." 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. Received in City Clerk's Office by Name of Deputy Clerk Document Control Number (Assigned by the City Clerk's Office) 23 Entered By ~vSNAN ~C'dCGE2 Date _ ~ ~/~~ T! r~ '~~'~~''~'~ '"'~'~~~`~ a~+®~s'~~re~~arary intemet FitesAOLK67fl\8C Application Revised 102907.doc