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Valentino Eriksen 03/15/2009 Cilp oiF Miami d~ach, 1700 Convention Center Drive, Miami Beach, Fbrida 33139, www.miamibeachfl.gov OFFICE OF THE CITY CLERK, Robert Parcher, Ciy Clerk TEI: (305) 673-7411, FAX: (305) 673-7254 TO Valentino Eriksen RE: Gay Business Development Ad Hoc 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: ~~/,15/2009 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 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. Valentino Erikse Sworn to and subscribed before me this ~_ day of a , 200~s Silvia Prieto 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 commifNed to providing excellent public service and saiey to all who live, work, and play in our vibrant, tropical, historic community. ~• NAME• ~~1 ~SE'n UR ~ -~~n O J - Last Name First Name Middle Initial HOME ADDRESS: _~ (C7© ~ ~' ~ 1 ~ ,Q ve ~ 3c? t Ivo. Street / " ~~ c~ n~ ~ 1 Yea ~~~ ~ L ~,~ City State Zip Codr PHONE: ~C~S- 7 ~C_ . ~'~ ~ c ~ ~ Home Work Fax ~'L~~S~obt~.Cp Email address Business Name: ~-~ t ~T Position: arc-~npf-o, AnG~o ~ V Address: 1C7!=i'? q ~~ tnq '~Ci~ /~..p /Yt ~., __. ~?__1 ~^. ~-, No. -~~Street ^ Professional License (describe) City State Zip Code Expires: rurauani io terry 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; orb) 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) month . Xes r No • Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months~~or No • Are you a registered voter in Miami Beac ~ Yes or No • (Please check one): I am now a resident of: North Beac South aeB ch fiddle Beach • 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) i- Art in Public Places Committee Beach Preservation Board C Beautification Committee .Housing Authority* Board of Adjustment* ~ Loan Review Committee* ~ Marine Authority* Budget Advisory Committee Committee on Homeless .Miami Beach Cultural Arts Council Committee for Quality Education in MB _ Miami Beach Commission for Women _ Miami Beach Florida Sister Cities Community Development Advisory* ,Convention Cpn}ar n,~,,.~„~„ o,.... `Normandy Shores Local Gov't Neigh. Improvement =Oversight Committee for General Obligation Bond ~~ r ~~a~ Debarment Committee ~ Parks and Recreation Facilities Board Design Review Board* =Personnel Board* =Planning Board* Disability Access Committee Fine Arts Board =Police Citizens Relations Committee Golf Advisory Committee =Production Industry Council .Public Safety Advisory Committee - Health Advisory Committee Health Facilities Authority Board .Safety Committee ffairs Committee ~ =Transportation and Parking Co 'ttee Historic Preservation Boa ' n ion Authon ~ Youth Center Advisory Board 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 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: Age: Program: Child's name: Age: Program: .Have you ever been convicted of a felony: Yes o N If yes, please explain in detail: • Do you currently have a violation(s) of City of Miami Beach codes: Yes ~r No) . If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money: Yes q'~ Nql If yes, explain in detail • Are you currently serving on any City Boards or Committees: Yes c(r NoJ 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 No hich departmdnt? _ • Pursuant to City Code Section 2-25 (b): Do you have a parent ,spouse ,child ,brother City of Miami Beach? Check all that apply. Identify the department(s): A i or sister who is employed by the This section is "not required" but desired: Age: ~~ years old Gender: Male ~/ Female Ethnic Or" n (Check one) White ,African-AmericanlBlack _ ~spanic: =Asian or Pacific Islander =~ American Indian or Alaskan Native Employment Status: Employed tired ^ Home-maker ~ Other =~ "1 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." ,,~ ---_ Applicant's Signature Date Name of Applicant (PLEASE PRINT) Please attach a copy of your resume to this application l NOTE: Applications will remain on file for a period of one (1) calendar year. ~- ~j~J('~Q C~ ~ ~c ~e J Received in Ciiy Clerk's Office by Date Name of Deputy Clerk Document Control Number (Assigned by the City Clerk's Office) Entered By Date Revised t0/29l20071. Hahietd