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Cynthia Romas 06/30/2009m ,'/',!q''~n,IBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, vvww.miamibeachfl aov OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk Tel: (305) 673-741 1, Fax: (305) 673-7254 August 26, 2008 Cynthia Roman 1880 So. Treasure Drive 2M North Bay Village, 33141 SUBJECT: COMMITTEE FOR QUALITY EDUCATION IN MIAMI BEACH Dear Ms. Roman: Congratulations! You have been appointed as a Representative of the PTA for the Treasure Island Elementary School to the above-referenced agency, board or committee for a term ending, 6/30/2009. If you are unable to accept this appointment, please notify the City Clerk's Office at (305) 673-741 1. Sincerely, ~ l ~~ J Robert Parcher City Clerk cc: Saul Frances, Parking Director Leslie Rosenfeld, Liaison 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 2-1 1.1 -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 ar~l~ei~drdcepn~ivv~:`ie~~gd4dnii>:iseFewir~and.~rd~!ct~15i~~A~rhiiv~ivepw,omkcbAid}pld~us~vi~ua:nrlbra~titic.~r~#cat; ~riBtarJci~ommunity. m /ViIA.%ViiBEACH NAME: ~ ~ \~ 1~~ iLa t a~mle Fi Nafine dle n' ' I HOME ADDRESS: 1 l.~ ~ ~ ~ ~ ~ / ~ ~ ~ ~ No. Street City State Zip Code PHON~IT.~CJ~ O ~ ~'1 ~~ ~wJ~`i ~ / l~ ~W~ ~n~~r~~~J~n il!' ht1i~ a ~jQ~YI Home Business Address: Professional License (describe) _ Work vu cc: ~;1~'~'` OF ~i~a: ~~~ _~~ ~i:~ ~I~IT~ ~,P.iC:. p s~..~ FOCI Fax miry Email State Zip Code Expires: .4ttacJr a copy of tt~e License 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) 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 • Are you a registered voter in Miami Beach: Yes ^ or No~ • (Please circle 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: riease ust 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) ^ Affordable Housin Adviso Committee ^ Health Facilities Authori Board ^ Art in Public Places Committee ^ His anic Affairs Committee ^ Beach Preservation Board ^ Historic Preservation Board* ^ Beautification Committee D Housin Authorit * ^ Board of Ad'ustment' ^ Loan Review Committee* ^ Bud et Adviso Committee ^ Marine Authorit * ^ Ca ital Im rovements Oversi ht ^ Miami Beach Commission for Women ^ Committee on Homeless ^ Miami Beach Cultural Arts Council Committee for Qualit Education in MB ^ Miami Beach Florida Sister Cities ^ Communit Develo ment Adviso * ^ Normand Shores Local Gov't Nei h. Im rovement ^ Communit Relations Board ^ Parks and Recreation Facilities Board ^ Convention Center Adviso Board ^ Personnel Board* ^ Cultural Arts Nei hborhood District Overla CANDO D Plannin Board ^ Debarment Committee ^ Police Citizens Relations Committee ^ Desi n Review Board* ^ Production Indust Council ^ Disabili Access Committee ^ Public Safet Adviso Committee ^ Fine Arts Board ^ Safet Committee ^ Ga Business Develo ment Ad Hoc ^ Trans arenc Reliabilit & Accountabilit Committee "TRAC ^ Golf Adviso Committee ^ Trans ortation and Parkin Committee ^ Green Ad Hoc Committee ^ Visitor and Convention Authorit * ^ Health Adviso Committee ^ Youth Center Adviso Board * Bnard Ronnirorl fn C:1., ca..a.. n:__:__..__ e c .away VAVIV.7VItl IVf111 F:ICLER\~ALL18&G AppiicationlBB~C Applicatior€ Revised 051808.doc 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 ~ or No!~If yes, please explain in detail: • Do you currently have a violation(s) of City of Miami Beach codes: Yes ^ or No ~f yes, please explain in detail: • Do you currently owe the City of Miami Beach any money: Yes ^ or No C~'~MF yes, explain in detail • 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: ~ Title: Name: / 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 N~1-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): This section is "not required" but desired: Age: ~ years old Gender: Male ^ Female'ff'~~ Ethnic Origin (Check one) White ^Rfrican-American/Black ^ Hispanic'.~I.Qsian or Pacific Islander ^ American Indian or Alaskan Native ^ "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 Please attach a copy of your resume to this application NOTE: Applications will remain on file for a period of one (1) calendar year. (PLEASE PRINT) Emolovment Status: Emolovedl~etired ^ Home-maker ^ Other ^ __ 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 04/18/08 LH F:ICLER\~Al_LtB&C ApplicationlB&C .Application Revised ~5'!908.doc. G-r t §~t j `° v ~. ~'.~.: _ ~, ~ .~ n 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) 673-741 1, Fax: (305) 673-7254 TO Cynthia Roman RE: Committee for Quality Education in MB 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: 06/30/2009. 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 Pub/ic Officers and Emp/ogees, 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. Cynthia Roman Sworn to and subscribed before me this ~ day o , 200 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 vibrant, tropical, historic community.