HomeMy WebLinkAboutDavid Neithardt
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City of Miami Beach Office of the City Cieri<
1700 Convention Center Drive, Miami Beach, FL 33139
Email: dtyderl<@d.miami-beach.f1.us
LOBBYIST REGISTRATION FORM
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(City of Miami Beach, City Code Chapter 2, Division 3, Section 2-481)
Q Check Box if an Amendment
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NAME OF toBBYlS r : . (La"
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(Number and Street)
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(First)
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(City)
(M.!) DATE QUA. UFIED AS L~YIST
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(State) (Zip Code)
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TELEPHON'E NUMBER: FAX NUMBER:
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I. L"'OBBYIsT RETAINED BY:
NAME o/~~Afcu;::~/T/k", If /~
EMAIL:
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(City)
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(Zip Code)
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BUSINESS ADDRESS: (Number and Street)
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TELEPHONE NUMBER:
FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill out this section if prindpal is a Corporation, Partnership or Trust [Section 2-482 (e)]
. NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
. UST ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II.
5PEaFIC~FE:
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Issue to be lobbied (Desoibe in detail):
III. CITY AGENCES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE,OR OTHER): ~
A~DISCLOSURE: -y..J2.', /7--/'4 ~.
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B) PRINOPAL'S DISCLOSURE (O~ COMPENSATION):
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V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CTY CLERK A SIGNED
STATEMENT UNDER OATH, USTlNG LOBBYING EXPENDITURES IN THE CITY OF MIAMI BEACH 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 S~ction 2-48~f the Miami Beach City Code as amended, and all
reporting requirements. ;~ /
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Signatureof~ f;/P'
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Signature of PrinCipaI/Client:(J~-- "'-\ \N ~. (.:.\
VI. LOBBYIST IDENTIFICATION:
~rOduced 10 fDLtJ3k3 171 b9 IOr-O
Form of Identification
~ersonally Known
VII. SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This ~ -tI, day of ~btr. 2002.
. OFFICIAL N
ULLIAN BEAUCHAMP
NOI'AllYPUBUC STATE OF FLORIDA
COMMISSION NO. 00109289
MYCOMMl5SION EXP. APR. 29.2006
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Print, stamp or type name of Notary Public
Registration:
FOR CLERK'S USE ONLY ;' /~
[ ] REJECTED DATE: 9/C, ,_
If rejected, state reason:
Registration fee paid: 1 She [1 ~MCR # 1-...-)51 ~
DATA ENTRY DATE: n""/ ~ . 2002 ENTERED BY: _
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I First Revision - 05/17/02
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