Pam RogersMIAMI BEA CH
City of Miami Beach
l 700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email : BC@miamibeachfl.gov
Telephone : 305.673. 7 411
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 ( ✓) all that apply):
X I am a resident of the City of Miami Beach for six months or longer.
Home Address: __ 5;:;;..4.;...1.:....:5""""C=ol:.:.:.li:...:cns::....:...;A:.:..ve.:::c•:..,...• .!.!.#.:::.50.:::.:5::::..,....!.M!.!;i~a:!.!.m.!!.i ~B:.!::e~a::::!ch.!.i.,...!.F..!:L~3~3!....!1c:::?4~0_
D I 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 Business: ---------------------------
Business Address: __________________________ _
D I 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 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.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts
sta~ it are true.
't1L-_ 12/01/2021
Signature Date
Pam Rogers
Printed Name
Received December 2, 2021
Office of the City Clerk