Standard Parking/VIP Parking
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City of Miami Beach Office of the aty aerie
1700 Convention Center Drive, Miami Beach, FL 33139
Email: dtyclerle@d.miami-beach.fl.us
LOBBYIST REGISTRA1l0N FORM
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(aty of Miami Beach, City Code Chapter 2, Division 3, Section 2-481)
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NAME OF L088YIST: (Last) (First)
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BUSINESS ADDRESS: (Number and Street) (aty)
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TELEPHONE NUMBER: FAX NUMBER:
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(M.I) DATE AUFIED AS LOBBYIST
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(State) (Zip Code)
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EMAIL:
I. LOBBYlSf RETAINED BY:
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NAME OF PRINCIPAL/WENT:
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BUSINESS ADDRESS: (Number and Street)
(aty)
(State)
(Zip Code)
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TELEPHONE NUMBER:
FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill out this section if prlndpalls a Corporation, Partnership or Trust [Section 2-482 (c)]
? NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
? UST ALL PERSONS HOlDING, DIRECTLY OR INDIRECTLY, A S% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
U. SPEOFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
m. cnv AGENOES/INDMDUALS TO BE LOBBIED:
A) Full Name of Indlvldual/T1tIe
B) Relationship
,
.
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETllER HOURL Y,
FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
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V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, USTING LOBBYING EXPENDITURES IN THE CITY OF MIAMI SEACH FOR
THE PRECEDING CALENDAR YEAR.
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 2-482 of the iami Beach City Code as amended, and all
reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
.05 Produced ID
F533-d-70- '+7-l/a-S: 0
Form of Identification
.05 Personally Known
VII. SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade
Sworn tp~ub~~~e
This I' day o. ~ 2002.
ture of Public Notary - State of Florida
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Registration: ~PTED
FOR CLERK'S USE ONLY / / ~
[ ] REJECTED DATE:?; li7 lJ
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DATA ENTRY DATE:
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ENTERED By:M~
I First Revision - 05/17/02