Mike Gibaldi (2)MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BU@miamibeachfl.gov
Telephone: 305.673.741 1
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (ch ck (J) all that apply):
LJ am a resident of the City of Miami Beach for t r longer. I y o six months o to ge .
Home Address:-4 780 Pf NC f zee �'jZ, 41 U 4Ax4) aL�FL
331q6
❑ 1 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 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 p n It�i s o per'dry I declare that I have read the foregoing document and that the facts
stated in,,
n i i'jtru .
l�
Signature _ Date
tt Ice
Printed Name