Marilys Nepomechie CITY OF MIAMI BEACH
BOARD AND COMMITTEE APPLICATION FORM
Nepomechie
Marilys
R
NAME:
_____________________________________________________________________________________________________
Last Name First Name Middle Initial
1743 Michigan Ave #5
FL
33139
HOME ADDRESS:_______
____________________________________________________Miami ___________Beach_____________________
AptNo. House No./Street City State Zip Code
305 348 1887Marilys.Nepomechie@fiu.edu
305 672 5327305 858 0849
PHONE:
____________________________________________________________________________________________________
Home Work Fax Email address
+ MRN Arch.
Architect + Faculty, Architecture
Florida International University
Business Name: _________________________________________Position:____________________________________________
FL
33199
11200 SW 8th StreetMiami
Address: ____________________________________________________________________________________________________
No. Street City State Zip Code
2013
AR 11173 --Architecture
Professional License (describe) _________________________________________________Expires:_______________Attach a copy of the 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; or b) an individual shall demonstrate ownership/interest for a minimum of six months in a business established in the city.
x
YesNo
or
x
YesNo
or
x
YesNo
or
xx
North BeachSouth BeachMiddle Beach
(Pleasecircleone): I am now a resident of:
Architect +
and experience. Please list below:
Professor of Architecture
x
YesNo
or
123Please note that only three (3)
Please list your preferences in order of ranking [] first choice [] second choice, and [] third choice.
choices will be observed by the City Clerk’s Office.
(Regular Boards of City)
Affordable HousingAdvisory CommitteeMarine Authority
Art in Public Places CommitteeMiami Beach Commission for Women
Beautification Committee Miami Beach Cultural Arts Council
Board of Adjustment* Miami Beach Human Rights Committee
Budget AdvisoryCommitteeMiami Beach Sister Cities Program
Capital Improvements Projects Oversight Committee Normandy Shores Local Government Neigh. Improvement
Committee on the Homeless Parks and Recreation Facilities Board
Committee for Quality Education in MBPersonnel Board
Community Development Advisory Planning Board*
Community Relations Board Police Citizens Relations Committee
Convention Center Advisory Board Production Industry Council
Design Review Board*Safety Committee
Disability Access CommitteeSingle Family Residential Review Panel
Fine Arts BoardSustainability Committee
Gay, Lesbian, Bisexual and Transgender (GLBT)Transportation and Parking Committee
Golf Advisory CommitteeVisitor and Convention Authority
Health Advisory CommitteeWaterfront Protection Committee
Health Facilities Authority BoardYouth Center Advisory Board
Hispanic Affairs Committee
1
Historic Preservation Board
x
Housing Authority
*Board Required to File State Disclosure Form
Loan ReviewCommittee
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 YesNo . 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:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application.doc
x
Have you ever been convicted of a felony: Yesor NoIf yes, please explain in detail:
__________________________________________________________________________________________________________
o you currently have a violation(s) of City of Miami Beach codes: Yesor No. If yes, please explain indetail:
x
_________________________________________________________________________________________________________
o you currently owe the City of Miami Beach any money: Yesor No x.If yes, explain in detail
__________________________________________________________________________________________________________
re you currently serving on any City Boards or Committees: Yesor No.If yes; which board?
x
___________________________________________________________________________________________________________
hat organizations in the City of Miami Beach do you currently hold membership in?
None
Name: ________________________________________________Title:______________________________________________
Name: ________________________________________________Title:______________________________________________
List all properties owned or have an interest in, which are located within the City of Miami Beach:
My home: 1743 Michigan Ave #5, Miami Beach, FL 33139
___________________________________________________________________________________________________________
I am now employed by the City of Miami Beach: Yesor No.Which department?
x
______________________________
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):
NO
_________________________________________________________________________________________________________
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.
Gender:Male Female
x
Ethnic Origin:Check one only (1)
White(Not of Hispanic Origin): All persons having origins in any of the original peoplesof Europe, North Africa or the Middle East.
African-American/Black(Not of Hispanic Origin): All persons having origins in any of the Black racial groups of Africa.
x
Hispanic:All persons of Mexican, Puerto Rican, Cuban, Central or South American, 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 Far 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 Indianor Alaskan Native:All persons having origins in any of the original peoples of North America, and who maintain
Cultural identification through tribalaffiliation or community recognition.
x
Physically Challenged:YesNo
or .
x
Employment Status: Employed Retired Homemaker Other ________________________________
NOTE:If appointed, you will be required to follow certain laws which apply tocity board/committee members.
These laws include, but are not limited to, the following:
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 for period of one year after leaving office (Miami
o
Beach CityCode section 2-26).
Requirement to disclose certain financial interests and gifts (Miami-Dade County Code section 2-11.1).
o
(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 570.611).
Upon request, copies ofthese laws may be obtained from the City Clerk.
“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 Code “Standards of Conduct for City Officers, Employees and Agency Members.”
Marilys R. Nepomechie
23 January 2012
______________________________ ______ ______________________________________________________________________________
Applicant’s Signature Date Name of Applicant (PLEASE PRINT)
Received in the City Clerk’s Office by : _________________________________ Date: __/__/2010 Control No. __________ Date: __/__/2010
Name of Deputy Clerk
City of Miami Beach,
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miamibeachfl.gov
CITY CLERKOffice CityClerk@miamibeachfl.gov
Tel: 305.673.7411 , Fax: 305.673.7254
Acknowledgement of fines/suspension for Board Members for failure to comply with Miami-
Dade County Financial Disclosure Code Provision Code Section 2-11.1(i) (2)
Board Member name
: _________________________________________________
July 1, of each year
I understand that no later than a
ll members of Boards and Committees of the City of
Miami Beach, including those of a purely advisory nature, are required to comply with Miami-Dade County
Disclosure Requirements. This means that the members of City Advisory Boards, whose sole or primary
responsibility is to recommend legislation or give advice to the City Commission, must file, even though you
may have been recently appointed.
You must file one
of the following with the City Clerk of Miami Beach, 1700 Convention Center Drive,
Miami Beach, Florida, by July 1 each year.
1.A “Source of Income Statement” (attached) or
2.A “Financial Statement” (attached( or]
3.A Copy of the person’s current Federal Income Tax Return
Failure to file, according to the Miami-Dade County Code Chapter 1, General Provision,
Section 1-5 may subject the person or firm to a fine not to exceed $500.00 or by imprisonment
in the county jail for a period not to exceed sixty days, or both.
_____________________________________________ ______________________
Signature: Date:
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application.doc