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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat or modification of
any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the City Manager or any city board or
committee; or any action, decision or recommendation of any city personnel during the time period of the entire decision-making process on such
action, deasion or recommendation that foreseeably will be heard or reviewed by the city commission,. or a city board or committee. The term
specifically includes the principal as weA as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 2004.3435.
.-•.
NAME OF LOBBYIST: (Last) (First) (M.I)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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NUMBER: FAX NUMBER: EMAIL:
LOBBYIST RETAINED BY:
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NAME OF PRINCIPAUCLIENT:
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
out this section if principal is a
or Trust
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~ ~/~ . ~~~ ~ ~ ~'"`Q
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST: `
II.SPECIFIC LOBBY ISSUE:
Issue to be lobbied (Describe in detail):
~Il. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to City Code section z-aez(g)
include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise to an
appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code Section Z-
46z(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the
commencement of service of City personnel to be lobbied.)
A Full Name of Individual Title B) An Financial, Familial or Professional Relationship
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A) LOBBYIST DISCLOSURE: (Required) ~~ (~ /..~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION)
(Required}.
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 288 E
On Procurement Issues":
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ntitied "Prohibited Campaign Contributions By Lobbyists
~•~~~~. ~~ scrwves or On e
present or pending award for goods eauioment or service
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
a~ofication for change of zoning mao designation or change to the C ri s Future Land Use
Mai?
3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of
"lobbyist" as set forth in Section 2-481 above) who only appears as a representative of anot-for-profit
corporation or entity without special compensation or reimbursement for the appearance, whether direct, or
indirect, to express support of or opposition to any item, shall register with the clerk as required by this
section but, shall not be required to pay any registration fees.
reimbursement. .
.~:ynmUfC VI LDDDy1S(
I do solemnly swear that all of th regoing facts are true and correct and that I have read or am familiar with the
provisions contained in Sect' 8 of the Miami Beach City Code and all reporting requirements.
Signature of Lobbyist: __ ~_ „
Signature of Principal/Client:
~. LOBBYIST IDENTIFICATION:
~, ~ s~ s s ~~ t~-
L1' Produced ID ~' ~~t'~ t `3 IIaC ~
^ Personally known
~~
VII. SIGNATURE AND STA L~FA~!
Z ~s si
tate of Florida, County of Miami-Dade ~,~•y oy~
Sworn to~d subscrib b fore me zA ~~ o
This day of ~~~ 2008 ~~°~~~~n
° ~~
~~s
i ature of Pu lic Notary -State of lorida
Notarization of Lobbyist's signature
TO BE COMPLETED BY CITY
Annual Registration fee: [ Yes [ J No Amount Paid ~
Lobbyist Registration Form received and verified by:
F:\C!_ER\NATL\Form~ ,lobby ,t Ric..-=,.,,,:.,, ~ :.nn:
PRINCIPAL IDENTIFICATION:
~, ~ Sw~s s ~~(. ~-
Produced ID ~ (~ (~ (o
Form of (dent
^ Personally known
~yc !~
State of Florida, County of Miami F~A~~ss'~ccy~
Sworn n~{subscri ed efore e
This ~ ~r ?iay of e 008 ~~~~oO~.o
5igr5ature of Publir/Nota~y -State of F
Notarization of Principal's signature
STAFFONL
Paid
Revised 03/27/2008
v SIGNATURE UNDER OATk:
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City of Miami Beoch, 1700 Convention Censer Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 , -Fax: 305.673.7254
LOBBYIST NAME;
CityClerk@miamibeachfl.gov
I understand that no later than October 1st of each year, I must file the following
forms, pursuant to Section 2-485 of the Miami Beach City Code, with the City C{ark's
Office for all active lobbying issues.
1) Lobbyist Expenditure Form
2) Disclosure Form
Failure to file these forms on a timely basis will result in my name being transmitted to the
Miami-bode County Commission on Ethics and for code violation evaluation.
In addition, once an issue I have registered to lobby on has been resolved, I am required
to immediate{y notify the City Clerk's Office of lobbyist withdrawal in writing.
Signature: Date:
i~avisacl 0?, 0~1 /2005