Pamela Mayer (2)City of Miami Beach
1700 Convention Center Drive
Miami Beath, Florida 33139
OFFICE OF THE CITY CLERK
Email: BCOmiamibeachfl gov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
i am in compliance with the affiliation requirement at Miami Beach City Code Sections 2-22 (4),
as (check (,t./) all that appy):
� I am a resident of the City of Miami Beach for six months or longer.,
01.1 �� �s �
Home Address.1P 3 I f
❑ FAM
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:
� I am a full-time employee of a business (for a minimum of six months) and l 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 f Business:
Business Address.
"Ownership InterestIVY means the ownership of ten percent (1056) or more (including the
ownership of 10% or more of the outstanding capital stock) in a business_
"Business" means any sole propfietorship., sponsorship, corporation, limited liability company,
or other enfify or business association.
Under penalties of penury, I decla
Signature
leel
Printed Name
do
that I have read the foregoing document and that the facts
Date'