Viola & Gary Violet 06/24/02
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-
City of Miami Beach Office of the City Oerk
1700 Convention Center Drive, Miami Beach, FL 33139
Email: cityderk@ci.miami-beach.f1.us
LOBBYIST REGISTRATION FORM
(City of Miami Beach, City Code Chapter 2, Division 3, Section 2-481)
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<(Fi1A\a~' ~TEQUrZAS33/3f
(Oty) (State) (Zip Code)
3oS--S 3 1.-0.sdO 305- S 3{",0(:541 k:.."'ro6~ek~'he.
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY: It.
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NAME OF PRlNGPAI../CUENT: 1--1
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BUSINESS ADDRESS: (Number and Street)
lO5-b 72.-..../ ~ 1'2
TELEPl-IONE NUMB~: .
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(Oty) (State) (Zip Code)
FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill out this section if prlndpal Is a Corporation, hrtnership or Trust [SectIon 2-482 (e)l
.
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
.
UST ALL PERSONS HOLDING, DIREcrLY OR INDIREcrLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II.
/
A) Full Name of Indivldual/Title
B) Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: # ~ I hG uJ'- - $ 21' ~.~ ,..
B) PRINQPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
~
V. SIGNATURE UNDER OATH:
. .
ON OCTOBER 1 Sf OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE crrY CLERK A SIGNED
STATEMENT UNDER OATH, USTING LOBBYING EXPENDITURES IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR.
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
I do solemnly swear that all of
familiar with the provision n
reporting requirements.
Signature of Lobbyist:
o Produced 10
Form of Identification
J Personally Known
VII. SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade
Swam ~~ SOT. bef~re m~
This J.. day 0 002.
Registration: ~
FOR CLERK'S USE ONLY
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[ ] REJECTED DATE:
If rejected, state reason:
Registration fee paid: [ ] Yes [ ] No
II] f:;Sh1[ ] Check
DATA ENTRY DATE: G/~ ~
1
MeR #
.2002
I First Revision - 05/17/02