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Belkys Nerey 12/31/2013 MIAMIBEACH 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)673-7411, Fax: (305)673-7254 1/6/2012 Belkys Nerey 8985 Bay Drive Surfsite, Florida 33141 S�II�JE`CF ,: Production Industry Council Congratulations! You have been reappointed by Commissioner Deede.Weithorn to the above referenced agency, board or committee for a term ending: 1213112013. If you are unable to accept this appointment, please notify the City Clerk's Office at (305) 673-7411. Please read the enclosed material carefully. Again, congratulations and good luck. Sincerely, Robert Parcher City Clerk cc: Saul Frances, Parking Director Graham Winick 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 2-11.1 - 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 are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community. MIAMIBEACH 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)673-7411, Fax: (305)673-7254 TO Belkys Nerey RE: Production Industry Council 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: 12/31/2013. 1 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 theFlorida 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 o ich I serve)on July 1 st,following the closing of the calendar year on which I have served. 7 Belkys Nerey i Sworn to and subscribed before me this cq5 day of , 2012. &luia p�to ki ko_�� N44-Wl 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. r "ITY OF 1011AMI BEACH A d x s s a u LIC �ION ORhd A�•"�rAME: 1�. �� � S ' Last Na Z � � �/ First Name � � �,/liddle I 'tial HOME ADDRESS: �J f Apt No. House No./Street City, State Zip Code PHONE: ® '" -3 f&S (-�I ff ilrS 1717-k .f /,Y,�/ C� Home Work Fax rmail a dress Business Name: Position: Address: No. Street City State Zip Code Professional License(describe) Expires: Attach a copy of the//cep se 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. • Resident of Miami Beach for a minimum of six(6)months:Yes4p or No ❑ • Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six(6)months:Yes❑or No [!P •Are you a registered voter in Miami Beach:Yes_'or No ❑ • (Please circle one): I am now a resident of: k North Beach South Beach Middle Beach • I am applying for an appointment because I have special abilities,knowledge and experience. Please list below: •Are you presently a registered lobbyist with the City of Miami Beach?Yes❑or No �t 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) ❑Affordable Housing Advisory Committee ❑Marine Authority ❑Art in Public Places Committee ❑Miami Beach Commission for Women ❑Beautification Committee ❑Miami Beach Cultural Arts Council ❑Board of Adjustment* ❑Miami Beach Human Rights Committee ❑Budget Advisory Committee ❑Miami Beach Sister Cities Program ❑Capital Improvements Projects Oversight Committee ❑Normandy Shores Local Government Neigh. Improvement 0 Committee on the Homeless 0 Parks and Recreation Facilities Board 0 Committee for Quality Education in MB ❑Personnel Board 0 Community Development Advisory ❑Planning Board* ❑Community Relations Board ❑Police Citizens Relations Committee ❑Convention Center Advisory Board roduction Industry Council ❑Debarment Committee ❑Public Safety Advisory Committee 0 Design Review Board* ❑Safety Committee ❑Disability Access Committee ❑Single Family Residential Review Panel ❑Fine Arts Board ❑Sustainability Committee ❑Gay, Lesbian, Bisexual and Trans ender GLBT 0 Transportation and Parking Committee ❑Golf Advisory Committee ❑Visitor and Convention Authority 0 Health Advisory Committee ❑Waterfront Protection Committee 0 Health Facilities Authority Board ❑Youth Center Advisory Board 0 Hispanic Affairs Committee ❑Historic Preservation Board 0 Housing Authority ❑Loan Review Committee *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: AND CQ"V-,;TTEES-BC'`.pplicai ion 1oc •Have you ever been convicted of a felony: Yes❑or Nolf yes, please explain in detail: 4'i;7* currently have a violation(s)of City of Miami Beach codes: Yes El or No °If yes, please explain in detail: Y • Do you currently owe the City of Miami Beach any money: Yes❑or No K If yes, explain in detail •Are you currently serving on any City Boards or Committees: Yes❑or No k�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 NoWhich 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. Gender: ❑ Male �IEemale Ethnic Origin: Check one only(1) ❑White (Not of Hispanic Origin):All persons having origins in any of the original peoples of 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. V)gmispanic: 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 Indian or Alaskan Native: All 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 Non. 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: • Prohibition from directly or indirectly lobbying city personnel(Miami Beach City Code section 2-459). • Prohibition from contracting with the city(Miami-Dade County Code section 2-11.1). • Prohibition from lobbying before board/committee you have served on for period of one year after leaving office (Miami Beach City Code section 2-26). • Requirement to disclose certain financial interests and gifts(Miami-Dade County Code section 2-1.1.1). (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 570.611). Upon request,copies of these laws may be obtained from the City Clerk. "I hereby est to the accuracy and truthfulness of the application and have received, read and will abide b ha r 2, Article VI of the City Co ` "Standards of Conduct for City Officers,Employees and Agency Members."r f 8eJ1C"( S Applica rt's signat Date Name of Appli nt(PLEASE PRINT) Please attach a opy of ur resume to this application NOTE:Applications will remain on file fora period of one(1)calendar year. Received in the City Clerk's Office by: `�-SAD Date:O'�l 1010�C,�trol No. Date: /_/201 Name o Deputy Clerk - MIA 1\A I BEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeochfl.aov CITY CLERK Office CifyClerkCm i amibeachfl.gov Tel: 305.673.741 1 , Fax: 305.673.7254. Acknowledgement of fines/.suspension for Board Mern bers for.failure to comply with Miami-Dade County Financial .Disclosure Code Provision Code'.Section 2-1101(i) (2) Board Member name: K 6 I understand that no .later than July L of each year all 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 fie,-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 lax'Retum 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 clays, or both. Signatur Date: M I A M FDADE ® SOURCE OF INC®ME STATEMENT Please Print or Type First Name Middle Name/Initial Last Name Disclosure 8e,( ^I For Tax Year Name: l V Ending: l Mailing Address: V l �'S �a- r►� City/State/Zip: Social Security Number: Filing as a: ® County Employee: ® Municipal Employee of: Position held or sought: Board where serving: � g V\VX y Term or Employment Began on: 7� c`o 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: Dome Address: Street Address City State Zip Code �I �i Please list below in descending order with the largest source first, the name, address and Il princiPal business activitY of every source of your income including public salary y®u , !I ii i received or any person received for your benefit or use during the disclosure per€od. The ! 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