Jeremy Wachtel (2)City of Miam'i B each
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl go,V
Telephone: 305.673.741"1
AFFIDAVIT OF AFFILIATION VITH THE CIN OF MIAMI BEACH
I am in compliance with the affiliation r
as (check (\/) all that apply):
di am a resident of the City of
Home Address:
r�
equirement of Miami Bleach City Code Sections 2-22 (4),
Miami each
(0 11/4.S
for six months or longer.
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❑ I have an ownership interest (for a minimum of six months) ir n a business established in the
City of Miami Bleach (for a minimum of six months).
Name of Business
en
Business Address
I am a full-time employee of
office or other location of t
minimum of six months). r
Name of Business: lG
a business (for a minimum of six months) and I am based in an
he business that is physically located in Miami Beach (for a
r�
Business Address.-
ko `'i`' ( I � I ""�' � Vt � Gl rh � �QG C� I" �
"Ownership Interest" means the ownership of ten percent (10%) or more
ownership of 10% or more of the outstanding capital stock) in a business.
(including the
10
"Businessmeans any sole propn"e-torship, sponsorship, corporation, limited liability com
or other entity or business association.
any,
Under penalties of perjury, I declare that I have read the foregoing document and. that the, facts
stated in it are tie.
nature
Printed Name
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