Alan Fishmancity of Miami Bc Odl
AFFILA` IT OF AFF!LAj!g DI! Tt!CiY���
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C>i tlf it }" OF- N41AMI-i3ADI,.
I am In Compliance with tate affiliation re:(tt.iirernent of t< i<arri E 4a€tty t ity f �tl,µy a��i€griS 1 (4), z� t (Check
all that apply)
0 f am a Iesident of the t. t'y (,i Miami Bead t0i' s'x months of is,ngef.
Hornere fdress4640 Post Avenue Miami i Buzicta, F L33140
i ha;lt'. 7(t C4�ddtlr`'C:`•hti3 !#at_ €f St (fvS e3 rr'i(' rr'rtlis'it of Si:K months) in a t3tiSaR%'SS eSt::rltati €s in the, (.:3t of
fa7ianni Beich, ;lora rt inir ium of s.x rntariths)
Busiriess Address____,
[3 i mi a tull-carne employee of a busif es if