Mohammed IslamMIAMI BEACH
Cly of Miami Beach
1700 Conwntion Center Drive
M'iami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
I am in compliance with the affi6ation requirement of Miami Beach City Code Sections 2-22 (4),
as<¥(,/) all that apply):
� am a resident of the City of Miami Beach for six months or longer.
�Address: .1.004, �i Cly:1t3 Jy:jy.g_., tvt'1Q� f?&4f½ h--3�14!:{
� have an ownership interest (for a minimum of six months} in a business established in the
City of Miami Beach (for a minimum of six months).
Name of Busu:1ess: 0 l,J n Pr 6P=:� >·
�Address: 3-::}½-:+-U I x::1'i>T, s-ry:.u+; M��C,VW\�0h.Pt;-33141
� am a full-time employee of a business (for a minimum of six months) and I am based in an
office or other location of the business that is physically located in Miami Beach (for a
minimum of six months}.
Name mBus�:� ��
�� =: BusinessAddress: 1"� � Y��L ,J��$f1SJ//tr�t M,� 1":>12.�u.... t;_-31\4\
"0Nners1yp Interest" means the Ownersf?ip af t�n percent (10%) or more (including theownership of 10% or more af the outstanding capital stock) in a business.
"Business" means a!'y sole . proprietorship, sponsorship, corporation, limited Ii b ·ittycompany, or other entity or busmess association. a 1
Under pe_nalties � I declare that I have read the foregoing docum ent and that th fa tsstated in • are t l (L L_I ,ii I� '.¼
e c
Signatu re , no::::;at;:::::e-;-l.,_,\"'7r-=::.....e=-------
MQHA-MM e.D K-AH G.v �l..AM.Printed Name
Received December 17, 2021
Office of the City Clerk