Colby Reese - Bicycle Sharing Program(~ ~ ce~cQe ~~
~~ MIAMIE-EAC I ~'°
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 modiFlCatiOn of
any ordinance, resolution, action or decision of any commissioner, any action, decision, recommendation of the City Manager or ar~ltty bt~! or
committee; or any action, decision or recommendation of any city personnel dudng the time period of the entire decision-making proeAss a~Gch ~'
action, decision or recommendation that foreseeably will be heard or reviewed by the city commission, or a city board or committee Thp~~e
specifically Includes the pdncipal as well as eny employee engaged 7n lobbying activities. The term "Lobbyists" has specific exelusl~. W ~,-~
refer to Ordinance 2004J435.
NAME OF LOBBYIST: (Last) (First) (M.Ij ~ yaM "r'
~~
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) N
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I. LOBBYIST RETAINED BY:
S%~Sl,~. l~~-~ wr~~~ ~' 33137
(Number
Fill out this section if principal is a Corporation, Partnership or Trust (Section 2.482 (c)j
• 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:
n SPECIFIC ~LOBBIf?ISSUE; (1e5L3~
Issue to be lobbied (Describe mdetail)/~ _ _ ~~~ ~~~ ~
w ,CITY AGENCIES_11NDNIDUALS TO CBE LO__B_BIE_D: Pursuant to City Code Section 2/-48`'2(g) Include
a statement of the extent of any business, financial, familial, professional or other relationship, giving rise to an
appearance of an Impropriety wRh 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 Clty to the present date, stating the general nature of the subject
contractual relation.
A Full Name of Indiv
idual Title B An Financial, Familial or Professional Relatlonshi
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RAC E OR OTHER): ~ / ~
PRINCIPAL'S DISCLOSURE (OF
A) LOBBYIST DISCLOSURE: (Required)
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The following information must be answered: `
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
O~n, Procurement Issues":
^ Yes LYNo: Are you lobbvinst on a present or oendinst bid for goods. eauigment or services. or on a
present or pending award for goods. eguigment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Este Development Issues":
agolicatton for chance of zoning map designation or change to the Citv's Future Land Use
Map?
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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
~sectio~n but, shall not be required to pay any registration fees.
^ Yes ILNVo: Are you regresent[ng anot-for-profit corporat[on or entiri w[thout special compensation or
reimbursement. .
PRINCIPAL IDENTIFICATION:
SIGNATURE UNDER OATH:
Signature of Lobbyist:
Signature of Principe
VI. LOBBYIST
~~~
Pr uced ID "~~0'IU7 ° ~7- ~'Ia' ~ ^ Produced ID
Form of Identification
^ Personally known
SIGNATURE AND STAMP OF NOTARY:
Form of Identification
^ Personally known (Principal)
State of Florida, my of Miami-Dade
Sworn and subscribed a[tme
This day of -~
'ublic Notary -State of Florida Signature of Public Notary -State of Florida
of Lobbyist's signature Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registretion fee: Yes.[ f No Amount~Paid $ MCR # / Date Paid /
LobbyisfRegistration rm'received and verified by:.
F:\CLER\;ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form 211Qg.doc rReVi5ed02/11/2009
of Florida, County of Miami-Dade
i and subscri before me 0 d
day of 13/u , ~ ~
I do solemnly swear that all oft o going facts are t ~-and correct and that I have read or am familiar with the
provisions contained in Sectio of the Mi~d~fi City Code and all reporting requirements.
'~ ~~~~~
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeochfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
CityClerk@m iam ibeachfl.gov
LOBBYIST NAME: ~ ~ l 'J~~ ~~`es~
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 j 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.
~~' ~-~~
Date:
F:ICLER\LOBBYIST1Lobbyist Registration Form 32708.doc