Romina Orozco-EncioMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC(av)miamibeachfl.aov
Telephone: 305.673.741 1
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (J) all that apply):
❑ I am a resident of the City of Miami Beach for six months or longer.
Home Address:
I have an ownership interest (for a minimum of six months) in a business established in the
City of Miami Beach (fora minim(umm of Tr months). C
Name of Business: A bF�V I f F Lo cf J T -
Business Address: )oog - -�j 5tr'e2-r M B t 'F) L4
❑ I am a full-time employee of a business (fora 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 of Business:
Business Address:
"Ownership Interest" means the ownership of ten percent (10%) or more (including the
ownership of 10% or more of the outstanding capital stock) in a business.
'Business"means any sole proprietorship, sponsorship, corporation, limited liability company,
or other entity or business association.
Un er p naltie of perjury, I declare that I have read the foregoing document and that the facts
t to i k.ac rue.
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Snature Date
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Printed Name