Nicole AllisonMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BCCcDmiamibeachfl.00v
Telephone: 305.673,7411
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):
0 1 am a resident of the City of Miami Beach for six months or longer.
345 Michigan ave #29 Miami beach FL 33139
Home Address:
0 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).
NIC Productions
Name of Business:
345 Michigan Ave #29 Miami Beach FL 33139
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 (1091o) 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
st`ated,iinf it are true.
Signature
N/ 4D 411,S%L-
Printed Name
(,a
Date