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David R. Custin~1~~~ ~~IN ~- l~ ~ ~~,,~ `; ~-. ~ 1 . 201111^ ~1~ 19 P1~ 3= 48 City of Miami Beach Office of the City Clerl~• !-~ •y~ , L ~; i{,' ~ C) ~_ ` I ~ i=~ 1700 Convention Center Drive, Miami Beach, FL 33139 LOBBYIST REGISTRATION FORM Lobbyist means all persons employed ~ retained, whether paid or not, W a principal who seeks to encourage the passage, defeat or modification of any ordinance, resolution, action or eleasion of any commissioner; any actmn, decis~n, recommeruialion of the City Manager or any dty board or committee: Ot any action, decision or recommendation of any city personnel during the time period of the entire decision-making process on such adior-, deasion or recommendation that foreseeabty will be heard or reviewed by the city commission, or a city board or committee. The term Specifx~liy includes the principal as weU as any employee engaged in lobbying activities, The term °t.obbyists" has sp~eciRc exclusions. Please refer m ordinance 2004Y-S5/. /'' ~ Lr S~r/I i /9 v, `~ rvAnntvrwtstsrl5r: (Last) r (First) (M.!) ,,, ~~ ~u' ~ ,~ ~-/`~S r- ®r ~c _ 6401 SW 113 PL, Miami, FL 33173-1083 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-412-3772 305-412-3773 .TELEPHONE NUMBER: FAX NUMBER: EMAIL: 1. LOBBYIST RETAINED BY: Choice Environmental Services, Inc. NAM!ME OF PRINCIPAUCLIENT: a /~ ,[~ / j'~~f / / ~ko,c~ ~/!/dr~~7~G~ ~ ( l ~ / C~~fn ~-r2`~ /~l'~~("r- L~iK~~l._- BUSlZES~NAGE % ~ADDR~S~ ~~ (Number and St eet) (City) (State) (Zip Codej ll ---- FAX NUMBER: (Optional) EMAIL: Fitt out this section if principal is a Corporation, Partrrership or Trust [~seyction 2-482 (c)) • NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: //~/e ~ ,Gj~ //P~ • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 531, OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: /_' ~~ ,!~`~ //~ Ii.SPEJCI/F)C LOBBY ISS/UE: to be lobbied iii. CITY AGENCIES/INDOVIDUALS TO BE LOBBIED: (Pursuant to city code section 2-482(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 2- 482(a](4) include a statement of arty contractual relationship (paid or unpaid) from 12 months preceding the commencement of service of City personnel to tae lobbied.) A Pull Name of Individual Title 8 An Financial, Familial or Professional Relationshi City Manager & administrative staff None Mayor and City Commission Comm Wolfson: design & printing; direct mail; prof. services Comm F_xposito: design & printing; diced mail; prof. services ~- RATE OR OTHER): A) LOBBYIST DISCLOSURE: (Required) ~J ®fl ~ ~~~~ ` B) PRINCIPAL'S (Required). <<Z (~~dl~,P ~ 0~T 2v~.2 5 S ~t o /t P~1~ The follawiing information must be answered: 1) Pursuant to Miami Beach City Code Section 21188 Entitled "Prohibited Campaign Contributions By Lobbyists On Procurement Issues": / Yes No: Are you lobbvinq on a present or pending bid for goods, equipment or services. or on a present or pending award for goods. equipment or service? 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": I Les I / INo: 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 City's Future Land Use M9D? 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 specal 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 tae required to pay any registration fees. n Yes n No• Are you representing anot-for-profit corporation or entity without special compensation or reimbursement V. SIGNATURE UNDER OATH: 1 do solemnly swear that provisions contained in Signature of Lobbyist: Signature of PrincipaUClient:` VI. LOBBYIST IDENTIFICATION: ^ Produced ID Form of Identification ^ Personally known (Lobbyist) VII. SIGNATURE AND STAMP OF NOTARY: State of Florida, County of Miami-Dade Swom_~~ubscribed b fore me This day ~p~$' ~O~C7 Signature rida Notarizati of Lobbyist's signature TO BE COMPLETED 8Y CITY Annual Registratlon fee: [ ]Yes [ ] No Amount Paid S 1 Lobbyist Registration Form received and verified by: -_,~ F:\CIER\MATL\Formi ,igbby~-: ~~y.:°-: ~~:,.; cf~.~....ar,r and that I have read or am familiar with the 81Reporting requirements. PRINCIPAL IDENTIFICATION: ProducedlD_~~3j-)fir;-6c/' ~UL'~ Form of Identifrcation ~. ;. .. ~~ ,i,,,,,,• IgAgEL SATGIEII =r Personally known (Princi ~ MY COttAMISSIONNDD879891 E EXPIRES: April 13, 2013 ~~.Rtt4'fi` Bc°dedThraNMa~YPuWkUnde~ers State of Florida, County of Miami-Dade Swom nd subscribed 4efore me 2O~p This day of ~ , 2898- Signatu a of Public Notary -State of Florida Notarization of Principal's signature q ~~' 4~~ Date Paid Revised 03/27/2008 i lily aF Miami 8eoth, 1700 Convention Center Dr'rve, Minmi Beach, Florida 33139, www.miomibeachfl.gov. CITY CLERK OfFice CityClericC~-miomibeachfl.gov Tel: 305.673.741 i ,Fax: 305.673.7254 LOBBYIST NAME: / ~ _ ______ _ ___ _ S" I _~ I understand that no later than Ocbber 1 s# of eoch ,xeas, I must file the following .forms, pursuant to Section 2 485 of the Miomi Beach City Code, with the City Clerk's Office for afl active lobbying issues. 1 j Lobbyist Expenditure Form 2j Disclosure Form Failure to file these forms on a timely basis will result in my name being transmitted to the Miami-0ade County Commission on Ethics and for code violation evaluation. In addition, once an issue I have registered to lobby on has been resolved, 1 om required to immediately notify the City Clerk's Office of lobbyist withdrawal in writing. Signature: Date: R.~visad 02/04r2Qi16