Carl Zablotny 03/15/2009
Cif~r of lNiomi dwch, 1700 Convention Center Drive, Miami Beach, Fbrida 33139, www.miamibeachfl.gov
OFFICE OF THE CITY CLERK, Robert Percher, City Clerk
TEI: (305) 673-7411, FAX: )305) 673-7254
TO Carl Zablotny
RE: Gay Business Development 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 f Miami Beach to which I have
been appointed for a term ending: 03/15/ Z oop
I have been issued a copy of Section 2-11.1 of the Miami-Da 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.
Carl Zablotny
Sworn to and subscribed before me this ~ day of 200
/1 ~ - •a _ ~
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 committed to providing excellent public service and safety to all who live, work, and play in our vibront, tropical, historic communiy.
NAME: /r
Last Name First Name ~J yyMidndle Initiial n
HOME ADDRESS: ~ ~ C) O ~ if /ifs ~'(- '°~- ~ ~('~, ') ~ ~~ IU . 5 I /_ / __t ~ I -- ~ ~1'
No. Street c' City States Zip Code
PHONE: ~~ ~ ~ ~,~ r ~ ~ ~ ~ ~~ ~~c'c C~ C~ d 3~ r 3~
Home -~ T Work Fax Email address
Business Name: Position:
Address:
No. Street City State Zip Code
Professional License (describe) 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; 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 es or No
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: es or No
• Are you a registered voter in Miami Beac : Ye or No
• (Please check one): I am now a resident of: North Beach outh B ach Middle Beach
• 1 am applying for an appointment because I have special abilities, nowledge, 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 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
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*
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
Visitor and Convention Authority*
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:
.Have you ever been convicted of a felony: Yes r No If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes ~ If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes ~ If yes, explain in detail
• Are you currently serving on any City Boards or Committe es or No If yes; which board?
• What organizations in the City of Miami Beach do you currently hold membership in?
Name:
Name:
Age: Program:
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 ~V'o~ .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): A~ /V'/
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 ^ 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 Co "Standards of Conduct for City Officers, Employees and Agency Members."
~_ ~ r ~~ `~ 1 C,,L -7` 1 ~ ~ J
Ap 'ant's Signature Date Name of Applicant (PLEASE INT)
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 Date
Name of Deputy Clerk
Document Control Number (Assigned by the City Clerk's Office) Entered By Date
Revised 7029/2007 L. Hatfield