Gayle O. Durham/MB Tennis Players Assoc..:
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
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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 20043435. I
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NAME OF LOBBYIST: nn(Last) ~~.~- ~~ l,{ n- (First) /^ (M.I)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER. FAX NUMBER: (Ootionall Gneeu • in.,*:.,.,~~~
Fill out this section if principal is a Corporation, Partnership or Trusi [Section 2-482 (c))
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
u.S'PECIFIC LOBBY ISSUE.:
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Issue to be lobbied (Describe in detail): ~
nl. CITY AGENC1ES/INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2-482(8) include
a statement of the extent of any business, financial, familial, professional or other relationship, giving rise to an
appearance of an impropriety with any City personnel sought to be lobbied -further, pursuant to City Code Section 2-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding said City
personnels' commencement of service with the City to the present date, stating the general nature of the subject
contractual relation.
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, FeAT ~
RATE OR OTHER):
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 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
^ Yes ~NO' Are you lobbying on a present or pendina bid for aoods equipment or services or on a
present or pending award for goods, eauipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes ~No• Are you lobbyinp on a pending application for a Development Aareement with the City or
application for change of zoning map designation or change to the City'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 ^ No: 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 C MPE ATION DURING THE REPORTING
PERIOD. I ~~ /J
of Lobbyist
I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am familiar with the
provisions contained in Section 2}82 of the~.Miami ,B'e~ch City C~de and all reporting requirements.
~` Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENT~ICATION:
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Produced ID ~ ~~~' ~' 2'? [ '~~. - 4 [!~ ~ 7
Form of Identification ~~ X ~ f
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^ Personally known (Lobbyist) ~ ~ ~
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SIGNATURE AND STAMP OF NOTARY:'' ° `"
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State of Florida, County of Miami-Dade .
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Sworn to and subscribed e~oN rry~e
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, 2009
This ~~ day of ;
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Signature of Public Notary -State of Florida
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Notarization of Lob~t ~
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PRINCIPAL IDENTIFICATION:
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Form of Identification
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personally known (Principal)
State of Florida, Coun of Miami-Dade
Sworn an subscrib efor me
This ~ da f 2009
Sign ur of Public Notary -State lorida
Nota ' ation of Principal's signature
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TO BE COMPLETED BY CITY CLERK'S STArr c~NLr
Annual Registration fee: [ ]Yes [ ] No Amount Paid $ MCR # Date Paid
Lobbyist Registration Form received and verified by:
~~ s`" _r? t~+~~.~'a2i~C3kt41~~~~~'h~z3~ ~~~~;~'~Labex~sr~~.: ~#~g~isir~Yizrr4 i~€a~•rr~: ~~4~~.d~~. Revised 02/11/2009
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
CityClerk@miamibeachfl.gov
L BBYI T N ~ ~ I~ --~ ~ ~' ~ ~ ~^'~
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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.
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Signature: Date:
F:\CLERIt_OBBYIST1Lobbyist Registration Form 32708.doc