Romina Orozco EncioC ity of Miami Beach
1700 Convention Center Drive
mibmmi Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: PBG.q&miamibeachfl.gov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
am in compliance with the affiliation requ
as (check (J) all that apply):
El i
irement of Miami Beach City Code Sections 2-22 (4),
am a resident of the City of Miami Beach for six months or longer.
Home Address
L� I have an ownership interes
t (for a minimum of six months) in a business established in the
City of Miami E eaCh (for a minimum oi six months),
Lo s 1
Name of Bus iness
❑ I am a full-time employee of a business (for a minimum of six months) and I am based
office or other location of the business that is physically located in Miami Beach
minimum of six months).
Name of Business#
Business Address:
do
in an
(for a
Ow-nership Interest" means the ownership of fen tx?rcenf (10 %) or more (including the
ownership of 70% or more of the outstanding capital stock) tn a,bu
siness.
"Business"means any sole proprietorship, sponso-rship, corporation, limited liability company,
or other entity or business associoation.
Und Ities of perjury, I declare th,at I have read the foregoing document and that the facts
St linit re true. /
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