Patrick FeeneyAAIA.M I BEAPCW
CitY Of Warni Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC miamibeachfi, ov
Telephone: 305_b737,411
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)1
as (check if that apply).-
� l am a resident of the City of Miami Beach for six months or I4nger.
Home Address.: 1500 Bay Road, Apt 1240, Miami Beach, FL 33139
EJ I have an ownership interest (far a minimum of six months)in a business established in the
City of Miami beach {for a minimum at pix months}_
4
Naive of Business:
Business Address.,
1 am a full-time employee of a business (far a min'16mum of sixmonths) and I am based in an
office r other location of the business that is physicallylocated in Warni Beach (for a
minimum f six months).
Name of Business:
Business Address.,
"Ownership Interest" means the
ownership
of ten
percent
{?0%} or more (including the
ownership of 10% or more of the
outstanding
capital
stock) in
a business.
'Business," means any sole propnetorship, sponsorship., corporation, limitedliabifity company.,
or other emit or business association,
Under penalties of perjury, f declare that I have read the foregoing document and that the facts
stated an it are Lrue.,-;P�
Signature
U
Printed Name