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Carmen Maria Lopez 12/31/2013 /V I I,A f��`,/,,1 B E AC�P City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139,www.miamibeachfl.aov OFFICE OF THE CITY CLERK, Rafael Granada,City Clerk Tel: (305) 673-741 1, Fax: (305) 673-7254 Email CityClerk @miamibeach.gov November 29, 2012 Carmen (Maria) Lopez 1050 W. 47" Street Miami Beach, Florida 33140 SUBJECT: FINE ARTS BOARD Congratulations! You have been appointed by Commissioner Michael Gongora to the agency, board or committee named above for a term ending: 12/31/2013. Pursuant to Ordinance No. 2006-3543, commencing with terms beginning on or after January 1, 2007, the term of board members who are directly appointed by a member of the City Commission shall automatically expire on December 31 of the year the appointing elected official leaves office. If you are unable to accept this appointment or have any questions, please call the City Clerk's Office at 305-673-7411. Please read the enclosed materials carefully. Congratulations again and good luck. Sincerely, Raf el E. Gran do City Clerk cc: Saul Frances, Parking Director Gary Farmer, Board 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, 2-458 and 2-459 Ordinance No. 2006-3543 -Amendment to City Code Section 2-22 Miami-Dade County Code Section 2-11.1 -Conflict of Interest and Code of Ethics City Wide Permit Application - (Parking Department Form) Booklet-Guide to the Sunshine Amendment and Code of Ethics for Public Officers We are committed to providing excellent public service and safety to aA who live, work and play in our vibrant, tropical, historic community. 1 MIAMI BEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139 vwvw.miamibeachfl.gov OFFICE OF THE CITY CLERK, Rafael E. Granada, City Clerk Tel: 305.673.741 1, Fax: 305.673.7254 Email: CityClerk@miomibeachfl.gov TO: CARMEN (MARIA) LOPEZ RE: FINE ARTS BOARD 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 Code of Ethics Ordinance), as well as the Florida 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* requirements of Miami-Dade County or the State of Florida depending on the board or committee on which I serve) on July 1, following the closing of the c endar which I have served. Carmen (Maria) Lopezl Sworn to and subscribed before me this day of T Al, , 2013. o Silvia Prieto Deputy Clerk *Please visit the City of Miami Beach website at www.miamibeachfi.gov under City Clerk/Board and Committees for additional information regarding the Financial Disclosure Requirement. F:\CLER\BOARD AND COMMITTIES DATABASE\Oath In Word\OATH.Docx CITY OF MIAMI BEACH MIAMI BOARD AND C0;0MITTEE APPLICATION FORM L v Pc z Last Name Fir t a C / Middle it f / c7 Home Address City tate 7 Zip Code `f o 7!� 5 V22 IUh-c--r2-C-9 0 V@ d Al Home Telephone Work Telephone Cellular Telephon E(nail address cAy2M e-A) Position: 0017 Business Name Business Address City State Zip Code 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 for a minimum of six months. • Resident of Miami Beach for a minimum of six (6)months: Yes or No ID • Demonstrate an ownership/interest in a busines�s jq Miami Beach for a minimum of six months: Yes U or No • Are you a registered voter in Miami Beach: Yes or No ID • I am now a resident of: 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 LJor No Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. easZnote that only three(3) choices will be observed by the City Clerk's Office. (Regular Boards of City) N ❑Affordable Housing Advisory Committee ine Arts Board ❑ Normandy Shores Logat Govscnment Neighborhood Im roV—ment-- ❑Art in Public Places Committee ❑Gay, Lesbian, Bisexual and Transgender ❑Parks and Recreationacilit Board' Enhancement Committee GLBT ❑Beautification Committee ❑Golf Advisory Committee ❑ Personnel Board ❑Board of Adjustment* ❑ Health Advisory Committee ❑ Planning Board* Ti ❑Budget Advisory Committee ❑ Health Facilities Authority Board ❑ Police Citizens Relations CoMmittee ❑Capital Improvements Projects ❑Hispanic Affairs Committee ❑ Production Industry Council Ln Oversight Committee ❑Committee on the Homeless ❑Historic Preservation Board ❑Safety Committee ❑Committee for Quality Education in MB ❑ Housing Authority ❑Single Family Residential Review Panel ❑Community Development Advisory ❑Loan Review Committee ❑Sustainability Committee ❑Community Relations Board ❑Marine Authority ❑Tennis Advisory Committee ❑Convention Center Advisory Board ❑ Miami Beach Commission for Women ❑Transportation and Parking Committee ❑ Debarment Committee ❑ Miami Beach Cultural Arts Council ❑Visitor and Convention Authority ❑Design Review Board* ❑Miami Beach Human Rights Committee ❑Youth Center Advisory Board ❑Disability Access Committee ❑Miami Beach Sister Cities Program 1 ❑Waterfront Protection 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 0 No '_vN. If yes, pl,efas . s t na]nnrs o'f d children, their ages,and which programs. List below: '` Child's name: Age: Program: n .0 Child's name: Age: Program: F:\CLER\5ALL\oFORMS\BOARD AND COMN1,1111EES\BC Application.doc •Have you ever been convicted of a felony:Yes Z3 or No`oyes, please explain in detail: • Do you currently have a violation(s)of City of Miami Beach codes:Yes Z)or No yes, please explain in detail: • Do you currently owe the City of Miami Beach any money:Yes ID or No yes,explain in detail • Are you currently serving on any City Boards or Committees: Yes ID or No Nd— 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: fi • I am now employed by the City of Miami Beach:Yes�or No E, .Which department? • Pursuant to City Code Section 2-25(b): Do you have a parent Z�, spouse E, child ID brother ID, 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. Ethnic Origin: Check one o Gender: Male I.J Female 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. 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,or 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�j or No Employment Status: Employed Retired LJ Homemaker Other NOTE: IF APPOINTED,YOU WILL BE REQUIRED TO FOLLOW CERTAIN LAWS THAT 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). • 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 2-11.1). • 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 bu ' ss or immediate family ties(CFR 570.611). Upon req est,copies of these laws may be obtained from the City Clerk. "I HEREBY ATTEST TH C AND TRUTHFULNESS OF THE APPLICATION AND HAVE RECEIVED, READ AND WILL ABIDE BY CHAPT A TI E VII — OF THE C TY CODE "STANDARDS OF CONDUCT FOR CITY OFFICERS, EMPLOYEES AND AGEN M S." Applicant's Signature Date Name of Applicant(PLEASE PRINT) Received in the City Clerk's O ce y: U—wk 12 me of De ty Clerk Control No. Defte ® ARTISTS 145 West 45th Street, Suite 1000, New York, NY 10036 TEL: 212-391-4545 FAX: 212-354-4941 CARMEN LOPEZ FILM 2 Days in New York Supporting Dir.Julie Delpy Handsome Harry Supporting Dir. Nicholas T. Proferes Promises Starring Dir. Joel Rodriguez/Warrior Pictures The Undying Supporting Dir. Steven Peros/Roscommon If You Only Knew Supporting Dir.Jorge Hemandez/BV Productions Hidden Rage Supporting Dir. Norton Rodriguez Patsy Supporting Dir.Anton Jarvis Undocumented Starring Dir. Joel Rodriguez Once Upon a Wedding Supporting Dir. Matia Karrell Just as You Imagined Supporting Dir. David Frankel La Americanita Supporting Dir. Erin Ploss-Campoamor 16 Blocks Supporting Dir. Richard Donner/Millenium Films Cadito's Way: The Beginning Supporting Dir. Michael Bregman/Universal It Runs in the Family Supporting Dir. Fred Schepisi/MGM Big Trouble Featured Dir. Barry Son nenfeld/Touchstone Our Song Supporting Dir.Jim McKay/Stepping Out Prod. Blood &Wine Featured Dir. Bob Rafelson/20th Century Fox Curdled Supporting Dir. R. Braddock, Q.Tarantino/Miramax Path to Paradise Featured Dir. Leslie Liebman, L.Williams/HBO Pronto Featured Dir. Jim McBride/Showtime Fair Game Featured Dir.Andrew Sides/Warner Bros. Virtually Yours Featured Dir.Antonio Marquer$to/EI Pico Scam Featured Dir. John Flynn/ShbMime Miami Blues Featured Dir. Kenneth Utt/Orion American Risci6 Featured Dir. Martin Dolman/Dania Fires Within Featured Dir.Gillian Armstrong/MGM Freedom Featured Dir. Norton Rodriguez/Ortiz Prod. TELEVISION Bum Notice Driver USA/Dir. Stephen Surjik The Jury Mamie Alou FOX/Dir.Jean de Segonzac The Unusuais Marianne Morales ABC/Dir. Ed Bianchi The Sopranos Nurse Alfeo HBO/Dir. Jack Bender All My Children Adelle Comstock ABC/Dir. Conal O'Brien Law&Order Gloria Manquez Universal/Dir. Lew Gould Sunset Gang Featured PBS/Dir. Uta Hagen Aqua Esta Alvarez Guedes Cast Member Empire Productions Charityn Guest Star Gems Television Network THEATRE (partial list) Noir Suspicions Claudette/Drunken Judge Fun Company(Musical) \ El Macho Bochinchera Jimenez The Bridge Theatre Cafe Noir Voodoo Priestess Murder to Go(Musical) Motel Singing Maid Pedro de Pool Production Que Pareja Caballeros Laughing Lina Raimundo H. Gato Production Murder Weekends Stand-up/Latin Star Dolphin Cruises Lines SKILLS Fluent Spanish, all dialects(comic or straight),Comedy writing, Stunts, Stand-Up Comedy Improv, Florida TRAINING Sitcom/Cold reading with Marci Phillips ABC Primetime, NYC Zuziki Method Actor Training/M. Martinez°Califc��ia State University d. Y Robbie Buckle Burns Acting Studios, Miami, FL SU Actors Studio w/Isle Earl Ph.D., Miami, FL Zpao uyor O N W J Z W 2 Q U MIAMI BEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office CityClerk @miamibeachfl.gov Tel: 305.673.741 1 , 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: /� /�l /`� I understand that no later than July 1, 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 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. /3 Signature: Date: n M o SOURCE OF INCOME STATEMENT Please.Print.or Type First Name Middle Name/Initial Last Name Disclosure Z For Tax Year Ending: ( D l Name' Mailing address: City/State/Zip: ,ember: Filing as a: County Employee: ® Municipal Employee of: Position held or sought: 7 ' )e_ ArT5 ✓O 0 Board where serving: 1j� e Term or Employment �� � .Began on: Department where employed: Work Address: If your home address is exempt from public records pursuant to VUoric Telephone: Florida Statutes 1119.07 please check here(read instructions): Home Address: Street Address 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: Description of the Principal N me of Source of Income Address Business Activity e_ 6 (" I h reby swear r affirm) that the aforesaid information is:a true and correct statement. 1 - /3 Signature o .person disclosing Date signed -