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Carmen (Maria) Lopez Board application package CITY CAF MIAMI BEACH i A!A M# SAC H BOARD AND CO EMI TEE AP P LICA T ION FORM L-6) 10 7 0A-PC_A1e-ti Last Name l/�n , , / First_Na / C /4 TL Middltiti� i , / O Home Address City J Zip Codes / 11 J I C-- e 606). d M Home Telephone Work Telephone Cellular Telephon6 iail address Position: 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 for No • Demonstrate an ownership/interest in a business io Miami Beach for a minimum of six months: Yes�J or No • Are you a registered voter in Miami Beach: Yesor No ID • I am now a resident of: North Beach U South Beach� Middle Beac • 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 Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. eas�note that only three(3)choices will be observed by the Citv Clerk's Office. (Regular Boards of City) r_-0 .rte ❑Affordable Housing Advisory Committee ine Arts Board ❑Normandy Shores Locq`a GovUtnm6n Neighborhood Im ro\�rTen�-- ❑Art in Public Places Committee ❑Gay,Lesbian, Bisexual and Transgender ❑ Parks and Recreation fiacilit Boarb'� Enhancement Committee GLBT 1 - ❑Beautification Committee ❑Golf Advisory Committee ❑ Personnel Board �' q ❑Board of Adjustment* ❑ Health Advisory Committee ❑Planning Board* tp ❑Budget Advisory Committee ❑ Health Facilities Authority Board ❑ Police Citizens Relations Cogj@wittee ❑Capital Improvements Projects ❑Hispanic Affairs Committee ❑ Production Industry Council to Oversight Committee 0 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 0 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 ❑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 No Z1. If yes, pl,eas�rhis t[,Pd � s o't I_ma children, their ages,and which programs. List below: `�i `' `;' s y Child's name: Age: Program: t , Child's name: Age: Program: i FACLER\WALL\flFORMS\BOARD AND CO,�r V,1TTEE`�\BC Apps cahon.d , I *Have you ever been convicted of a felony:Yes�j or No Uf yes, please explain in detail: • Do you currently have a violation(s)of City of Miami Beach codes:Yes�:]or No yes, please explain in detail: • Do you currently owe the City of Miami Beach any money:Yes 0 or No yes,explain in detail e Are you currently serving on any City Boards or Committees:Yes 0 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 1:3 or No .Which department? • Pursuant to City Code Section 2-25(b): Do you have a parent 0, 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. Ethnic Origin: Check one on Gender: Male U Female UWhite (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 0 or No Employment Status:Employe Retired 4D Homemaker 1:3 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: • 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 rest, ss or immediate family ties (CFR 570.611). Upon req copies of these laws may be obtained from the City Clerk. "I HEREBY ATTESWGM AND TRUTHFULNESS OF THE APPLICATION AND HAVE RECEIVED, READ AND WILL ABIDE BY VII — OF THE C TY CODE "STANDARDS OF CONDUCT FOR CITY OFFICERS, EMPLOYEES AND Applicant's Signature Date Name of Applicant(PLEASE PRINT) t l� ce y: � 1 Received in the City Clerk's O 0 me of De ty Clerk Control No. D e 1 r ARTISTSE 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 Hernandez/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 Carlito'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 McBrie/Showtime Fair Game Featured Dir.Andrew Sipes/ Warner Bros. Virtually Yours Featured Dir.Antonio Marqueei'to/EI Pico Scam Featured Dir. John Flynn/Showtime Miami Blues Featured Dir. Kenneth Utt/Orion American Riscib Featured Dir. Martin Dolman/Dania Fires Within Featured Dir.Gillian Armstrong/MGM Freedom Featured Dir. Norton Rodriguez/Ortiz Prod. TELEVISION Burn Notice Driver USA/Dir. Stephen Suoik 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 i 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 0% Zuziki Method Actor Training/M. Martinez!CalifQ�qiia State University n,ei d Robbie Buckley Burns Acting Studios, Miami, FL Actors Studio w/Isle Earl Ph.D., Miami, FL 6 m z r O m m N i u /r © John Gertz