Christopher Colgan
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, decision 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 well as any employee engaged in
lobbying activities. The teen "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
NAME OF LOBBYIST: ast) first) (M.I)
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BUSINESS NAME AND DDRESS (Number Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
LOBBYIST RETAINED BY:
NAME OF PRINCIPAUCLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: (Optional) II~AIL: (Opt(Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
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• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: "'~ q
G1~ r ~ 5'~o pher 'C..al ~cun, '1vlc~~lne~ Lo rrC~ ne .
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTERE&T INS'
SUCH CORPORATION, PARTNERSHIP OR TRUST: ~.~ ~
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ll. SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
Ill. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) .~
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): ~~
(Required).
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
application for change of zoning map designation or change to the Citv's Future Land Use
Map?
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 snot-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.
^ Yes ~lo: Are you representing anot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1sT OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL
BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPT~N DURING THE REPORTING
PERIOD. /~ .. ~//
Signature oftobbyist
I do solemnly swear that all of th oing facts
provisions contained in Sectio -482 the Miap~t'
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to a~d subscribed before me
This (o day of Sc,.~, 200q
,-~
igna re of lic No -State of Florida
yist's signature
correct and that I have read or am familiar with the
ode and all reporting requirements.
PRINCIPAL IDENTIFICATION:
^ Produced ID
Form of Identification
~ Personally known (Principal) •••••••N•N"~ ~~ """"°'s
GoinII~000b~116Z
~ ExpYes 1/~1R011
State of Florida, County of Miam~D ~~~'~"'•~
Sworn ar~d subscribed before me"""'...~..•....«..
This rc~-- ay of ~~v~, 20(~
Signa f Pu o a tate of Florida
Notariza ' 'al's signature
TO BE~OMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes [ ] No Amount Paid $ ~~'
MCR # Date Paid Z3 f3
Lobbyist Registration Form received and verified by:
Revised 02/04/2008
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City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachH.gov
CITY CLERK Office CityClerk~miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME:
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 Clerk'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-Dade 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 immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
Signature:
~ ~ ~°)
Date:
Revised 02/0412008