Old Dominion LTDCity of Miami Beach Office of the Oty Clerk
1700 Convention Center Ddve, Miami Beach, FL 33139
Email: cityderk@ci.miami-beach.fl.us
LOBBYIST REGISTRATION FORM
(City of Miami Beach, City Code Chapter 2, Division 3, Section 2-~81)
~ Check Box if an Amendment
NAME OF LOBBYIST~ (Last) (~ (M.I)
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BUSINESS ADDRESS: (Number and Street) (City) (State)
TELEPHONE NUMBER:
DATE QUALIFIED AS LOBBYIST
(Zip Code)
FAX NUMBER: EMAIL:
%. LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
(City) (Zip Code)
BUSINESS ADDRESS: .~.~ ?/umber and Street)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section if principal Is a Corporation, Partnership or Trust [Section 2-482 (c)]
· NAME OF CHIEF OFFICEP~ PARTNER, OR BENEFICIARY:
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· LIST ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
1%1. CITY AGENCTES/INDZVZDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Relationship
L.
City of Miami Beach Office of the City Clerk
1700 ConventJon Center Ddve, Miami Beach, FL 33139
Emaih cityderk@d.miami-beach.fl.us
LOBBYZST REGTSTRATZON FORM
(City of Miami Beach, City Code Chapter 2, Division 3, Section 2-481)
~ Check Box if an Amendment
NAME OF LOBBY[S-I': (Last) (First) (M.[) DATE QUAITFIED AS LOBBY[ST
BUS[NESS ADDRESS: (Number and Street) (City) (State) (7ip Code)
TELEPHONE NUMBER: FAX NUMBER: EMA[L:
Z. LOBBY/ST RETAINED BY: ·
NAME OF PRINCIPAL/CLIENT:
(city) (zip Code)
BUSINESS ADDRESS: .~.~. ~(~umber and Street)
TELEPHONE NUMBER: FAX NUMBER: (Op~onal) EMAIL: (Optional)
Fill out this secUon if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
· NAME OF CHIEF OFFICER, PARTNER, OR BENEFIC/ARY:
14. MoLl-,
· LIST ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORA'I'~ON, PARTNERSHIP OR TRUST:
[.;z iY AGENCZES/ZNDZVZDUALS TO BE LOBBZED:
A) Full Name of Individual/Title B) Relationship