Cynthia J. Brown/Miami Beach Gay Pridem MIAMIBEACH
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 term "Lobbyists" has specific exclusions. Please
refer to OMinance 2004-3435. •--~
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BUSINESS IV7{701~ CND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL: ~
I. LOBBYIST RETAINED BY:
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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) EMAIL: (Optional)
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Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)j
• ~AME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
• IDENTIF ALL ERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
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n SPECIFIC LOBBY, ISSUE:
Issue to be lobbied
nl. CfTY "AGENCIES/INDIVIDUALS TO BE LOBBfED: 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
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYISZ.QISCLOSURE: (Required)
B) PRINCIP-AFL' ''DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required).
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 288 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues°:
^ Yes l~o: Are you lobbvinq on a present or pending bid for goods, 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 lobbvinq on a pending application for a Development Agreement with the City or
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 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. .
V. SIGNATURE UNDER OATH:
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: ~.
L1d~Produced ID _
Form of Identifica
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF
State of Florida, County of Miami-Dade
Sworn t~~ subscri d bggfor me
This ~ -"! ~Y of~ f/~/~ , 2009
'ublic Notary -State of Florida
of Lobbyist's signature
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PRINCIPAL IDENTIFICATION:
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_ Produced ID l~
Form of Identification
^ Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn a d subscri d bef a me
Thi day o , 2009
Signat o Public No a - of Florida
Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: Yes [ ] No Amount Paid $ MCR # ~..
Lobbyist Registration Form received and verified by: /~ n
F:~CIER~$ALL~aFORMStLOBBYIST FARMS\tobbyist Registration Form 21109.dot _ .'~
Paid
Revised 02/11/2009
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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 2-4~pf the Miami Beach City Code and all reporting requirements.
m MIAMIBE.,~ ;
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, voww.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: t
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 Clerk's
Office for all active lobbying issues.
i ~ 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 withdraws! in writing.
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Signature: Date:
F:ICLERILC?BBYIST1Lobbyist Registration Form 32708.doc