Sunny WeberCty of NOMI& Be
1 700 Convention C
h
ter Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: B mia iheachfi.gov
Telephone: 305.673.741 1
AFFIDAVIT OF AFFILIATION WITH T
OF MIAMI BEACH
4
I am in compliance with the affiliation requirement of Miami' Beach CityCode Sections 2-22 (4),
as (check (✓) all that apply):
[Z I am a resident of the City of Miami Beach for six months or longer.
Home Address:
Q 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:-��ev�-� �P�-C�l�� tcLe-i>c)-e,('- Ir
Business Address: � 3 � al �•.5 � � 3c
am a fullAime employee of
once or other location o
minimum of six months),
Name of Business.
Business Address:
f t
a business (for a minimum of six months)
he business that is physically located in
and I am based
Miami Beach
in an
(for a
"Ownership Interest" means the ownership of fen percent (70%) 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,
stated in it are true.
Sig6ature
Printed Name
declare that I have read the foregoing document and that the facts
,, �Cto e-- �
Date
SCD %ft�_ - D