Tiffany Lapciuc 12/31/2011•
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~~ ~ ~ City of MiamiBeach, 1700. Convention Center Drive, Miami Beach, Florida.33139,.~wwvv.miamibeachfl.~ov
`' OFFICE OF TWE CITY CLERK, Robert Parcher, City Cierk~ ~ ~• ~ ~ •
. Tel: (.305) 673 741.1, Fox: (305).. 673-7254 ' •
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"05-12-2010 ' ,
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-Tiffany Lapciuc. ~.
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. ~~B~~~Y: IVliami~ Beach C®m~tnission For Wo~ren ' :~.
• ~ Congratulations! You have been.appointed by Corr'missioner Deede•Vl/eithorn
to theagency, board or.committee named above for a term ending: 12/31/2011.
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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 they year the appointing ~ •
elected official-!eaves office:
If you are unable to accept this.appointment or have any questions; please call the City •
.. Cferk's:Office at•305-673=7411. Please read the,enclosed materials carefully. -
Congratulations again and good fuck... -
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Sincerely, ~ ,
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°Robert'Parcher - ~ . ~ ~.
. City Clerk ~ ~ ~ ~ ~ .
:cc:-,Saul Frances, Parking Director ~ ` .
Wanda - Ortiiz . ~ - - _
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~TT'ACHMENTS:
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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.2fi459
10rdiriance ~No. 2006-3543 -~-Amendment to .City CodeSection 2=22 ~`
Miami-Dade County Code Section 2-11.1 -Conflict of interest and Code of 'Ethics .Ordinance .
City Wide ~Rermit Application - (Parking,Department Form}
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Booklet =Guide to the Sunshine.Amendment and Code of Ethics for"Public Offircers andEmployee.
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• : We are committed to providing excellent pu6Gc service and safely to all who live,,work and play,in our vibrant, tropical, historic community.
m MIAMIL~r~~C-8
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 Tiffany Lapciuc
RE: Miami Beach Commission For Women
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: 5/11/2010.
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 Officers 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.
`~
ffany L pciuc
Sworn to and subscribed before me this day of , 2010.
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.
m Mf~~~lll~f~~~~
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CI1P1~ 04~ RfilO~,RA9 191E~CE~
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Last Name ~ 'First Name ~ ~ Middle Initial
FIOME ADDRESS: ~ ~~t~ i'" %tI ~ l ~~"<~~l ~~ ~~~:'`I~II G~:J`'~J 1~C.1. ~~~~~
Apt No. House No./Street City State Zip Code
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.PHONE:. ~.~ ~ ~`~, ~" ,~ -~ ~ C3c~' J '~~.~.~ C„~~j.S>. ~/-~`~ Z(n ~~ J"~fZT /C,~' l.L
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Home ~ Work Fax Email address
Business Narne: _ ~ Position: ~ - `
Address:
No. Street City . State Zip Code
' Professional License (describe) Expires:. ,~~ach'a copy ®is ~e tiae~se
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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
Are you a registered voter in Miami Beach: Yes or No ^
• (.Please circle one}: ! am now a resident of: North Beach South Beach Middle Beach
• 1 am appl i for an appointment'~ecause I have special abilities, knowledge and experience. Please list below:
.Are you ~resently a registered lobbyist with the City of Miami Beach? Yes ^ or No ~
Please list yourpreferences in order of ranking [1J 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)
^ Affordable Housin Adviso Committee ^Housin Authorit
Art in~Public Places Committee ^ Loan Review Committee
Beautification Committee ~ ^ Marine Authorit
^ Board of Ad'ustment* Miami Beach Commission for Women
^ Bud et Adviso Committee ^ Miami Beach Cultural Arts Council
^-Ca itaf lm rovements Pro'ects Ove~si ht Committee ^ Miami Beach Sister Cities Pro ram
^ Committee on the Homeless ^ Normand Shores Locat Government Nei h. Im rovement
Committee for Qualit Education in MB ~ ^ Parks and Recreation Facilities Board
Comnunit Develo merit Adviso ^ .Personnel Board
Communit Relations Board ^ Plannin Board*
^ Convention Center Adviso Board ^ Police Citizens .Relations Committee
Debarment Committee ^ Production Indust Council
^ Des'r n Review Board* ^ Public Safet Adviso Committee
^ Disabilit Access Committee ^ Safet Committee
^ Fine Arts Board ^ Sin le Famil Residential Review Panel
Ga ,.Lesbian,`Bisexual and Trans ender GLBT ^.Sustainabilit Committee
Golf Advisor Committee ~ ^ Trans arenc Reliabilit & Accountabilit Committee "TRAC"
Health Adviso Committee ^ Trans ortation and Parkin Committee
^ Health Facilities Authorit Board _ ^ Visitor and Convention Authorit
^ His anic Affairs Committee ^ Waterfront Protection. Committee
^ :Historic Preservation Board ~ ^ Youth Center Adviso .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:
F:\CL€R\$ALL\aJ=ORM5\BGARD AND COMMITTEES\BC Application0626Q9 NEW.doc
.Have you ever been convicted of a felony: Yes ^ or No ~f 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 ^ 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:
.1 am now employed by the City. of Miami Beach: Yes ^ or No^,/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):
The following information is voluntary and is .neither part of your application nor has any bearing on your consideration for appointment. It is
being asked to comply with federal equal opportunity reporting requirements.
Gende-r' ^ 'Male C~` Female -
Ethnic Origin: Check one only (1)
White (Not of Hispanic Origin): Alf persons having origins in any of the original peoples of Europe, North Africa or the Middle East.
^ .African-AmericanJBlack (Not of Hispanic Origin): All persons having origins in any of the Black .racial groups of Africa.
^'Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South Amencan, or other Spanish culture or origin, regardless of race.
^ Asian or Pacific Islander: All persons having origins in any of the original peoples of the Fad East, Southeast Asia, the Indian Subcontinent, on
the Pacific Islands. This area includes, for example, China, .India, Japan, Korea, the .Philippine islands and Somoa.
American Indian. or Alaskan Native: Alf persons having origins in any. of the original peoples of North America, and who maintain
Cultural identification through. tribal affiliation or community recognition..
Physically Challenged: Yes ^ or
Employment Status: Employed ^ Retired ^ Homemaker ~ Other ^
NOTE: If appointed, you will be required to follow certain laws which apply to city board/committee members.
These laws include, but are not limited to, the following:
o Prohibition from directly or indirectly lobbying city personnel (Miami Beach City Code section 2-459).
o Prohibition from contracting with the city (Miami-Dade County Code section 2-11.1).
o Prohibition from lobbying before board/committee you have served on ford period of one year after leaving office (Miami
Beach City Code section 2-26). '
o Requirement to disclose certain financial interests and gifts (Miami-Dade County Code section 2-11.1).
(re: CMB Community Development Advisory Committee): prohibition, during tenure and for one year after leaving office,
from having any interest in or receiving .any benefit from Community Development Block Grant funds for either yourself ,
or those with whom you -have business or immediate family ties (CFR 570.6;11). -
Upon request, copies of these laws may be obtained from the City Clerk.
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"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 C de "Standards of Conduct for City Officers, Employees and Agency Members."
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Applicant's $i atur~ Date Name of Applicant (PLED, E PRINT)
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.Please attach a,copy of your resume to thispplication; ~~.~ __-~~
NOTE Ap hcations will remain on fil for a period_of one_(1)_calendar ye
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Received in the City Clerk's Office by : Date//2010 Control No. ~~ Date: /_/2010
Name o epu er F:ICLER\$ALL\aFORMSIBOARD AN C MMITTEES\BGApplication.doc
M I A M I~DADE ,
~ SOURCE. OF INCOME STATEMENT
Please Print or Type First Name Middle Name Initial Last Name
Disclosure
~ For Tax Year
Name:
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Mailing Address: ~ ~ QQ_„ Jul ~/~
City/State/Zip: ~ ~~ ,; ~~ f yb
Social Security Number: -
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Filing as a: ~ County Employee:
® Municipal Employee of: .
Position held or sought:
Board where serving: ~ If~~~ Term or Employment
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~ Be an on:
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Department where employed:
Work Address:
If your home address is exempt from public records pursuant to
Florida Statutes § 119.07 please check here (read instructions): ® Work Telephone:
Home Address: ~ I -1 ~ CJ ~~ {~(~ T~Q~Q,. ~ ~ l ~~ .
~j~ /~ - Street Address;
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,City State Zip Code
Please list below in descending order with the largest source first, the name, address and
principal business activity of every source of your income including public salary you
received or any person received for your benefit or use during the disclosure period. The
income of your spouse or any business partner need not be disclosed. If continued on a
separate sheet, check here: ~
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~ Description"of he.Princpal~
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Name;;of Source,of Income,., `~ Addre
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I hereby swear (or affirm) that the aforesaid information is a true and correct statement.
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Signature of perso isclo ng ~ Date signed