Shoji Restaurant, LLC
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City of Miami Beach Office of the aty Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
Email: dtyderk@d.miaml-beach.f1.us
LOBBYIST REGISTRATION FORM
(City of Miami Beach, City Code Chapter 2, DMsion 3, Section 2-481)
15 Check Box If an Amendment
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NAME OF LOBBYIST: (Last) (First) (M.!) DATE QUAUFIED AS LOBBYIST
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BUSINESS ADDRESS: (Number and StreJ) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
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NAME 0 RINCIPAl./CUENT:
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BUSINESS ADDRESS: (Number and Street) (City) (State)
(60 <\) S:;8A qqqt,.
TELEPHONE NUMBER:
83139
(Zip Code)
FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill out this section if prindpalls a Corporation, Partnership or Trust [Section 2-482 (e)l
?
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
mri.v:> a. . ~
UST ~LL PERSONS HOLDI~G, DI~rnY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
?
II. SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
DI. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Relationship
..,I.
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSAnON (DISCLOSE WHETHER HOURL Y,
FLAT RATEOR OTHER):
A) LOBBYIST DISCLOSURE: f fa ~ rY'\ tt
(~l1S'.Jh/) .
,
B) PRINOPAL'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, LISTING 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 con . d i Section 2-482 of the Miami Beach City Code as amended, and all
reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENnFlCAnON:
IS Produced ID
Form of Identification
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VII. SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade
Sworn.tPird subscribed ~~re m,e
This ~day of C) ..; 2002.
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Signature of Public Notary - State of Florida
.,.~~ Crisele Torres
!:~"'A~ ~~ MY COMMISSION' CC778123 EXPIRES
~~::&-1J January 9, 2003
\1.;r,p.f..r..~" BONDED THRU TROY FAIN INSURANCE, INe.
Print, stamp or type name of Notary Public
FOR CLERK'S USE ONLY
Registration: [~CCEPTED [] REJECTED
DATE:
L 0 ~&~OQ....-
If rejected, state reasop: _-
Registration fee paid: .f<TYes [ ] No "t--I ~
[ ] '1'" ~ MCR · ''''> "l . '
pATA ENlRY DATE: J 0 I f? ' 2002 ENTERED BY _2
1 First Revision - 05/17/02
IV. DISCLOSURE Of TERMS AND AMOUNTS OF LOBBYIST coMPENSAnON (DISCLOSE WltnHER HOURLY,
FtATRATEOR OTHER):
A) LOBBYIST DISO.OSURE: _ I r 1..dL IY'"' tt ~ ~..L.a
(tIl1S Jhr ') .
,
B) PRINCIPAl 'S OlSClOSU~ (()F LOBBYIst COMPENSATION): ptJ.L& oY\ a VVt Il'II\.Sl..PJ.. art (fA 4/'0: .
4B~.sLh{ .
;
V. SlGNA1VItE UNDER OATH:
ON octOBER 1St OF !ACtl YEAR, EACH LOBBYIST SHALL SUBMIT to THE ClTY CLERK A SIGNED
STATEMENT UNDER OATH, US11NG LOB8YJNG EXPENDITURES IN THE atY OF MlAMI BEACH FOR
THE PRI!!CEDING CALENDAR YEAR..
I do solemnly sweat' that elll of the foregoing fads are true and correct:. and that I have read ot' am
familiar with the provlslom con t 5ectton 2-482 of the Miami Beach Oty COde as amended, and all
reporting requirements.
SIgnature of Lobbyist::
~ Ptoduced ID
Signature of PrIncipal/alent:
VI. LOBB\'1ST mEN11FICAnoN=
---' .-
I.S -eally K~ry
va. SIGNATURE AND $I AMP OF NOTARY Ok DEPUTY CLERIC:
state of Florida, County of Miaml~Dade
Swom.tp.1spd subsaibed ~-r m~
This ~day of ~:) r 2002.
"'''.'''''
.4'!r.~. Cisek! Torres
~~;~ MY CO'4MtSSION.. CC778123 EXPIRES
~. . -- JOI1Udl)l 9, 2003
v..Jif.:" gO~D~b 1J.4~u TRO'< "AIN ItmJtlANCt I~
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Signature d Public Notary - state of Rorlda
Print, stamp or type name of Notary Public
FOR CLERK"S USE ONLY
Registration: ~ ACCEP11:D [J REJECreD
DATE:
lAl ~ 8 .. 0'1.-
If rejected, state rwson:
ReglWatJon fee pair;!: ttessh [ ] NOChedc MeR' 12- t:; ~ \ Y: 1-
PATA ENTRY DATE: D '5 2002 ENTERED BY: ~.
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State of Florida, County (>>(Miami-Dade
Sworn to and subscribed before me
this]~ day of O(...TD~. 2002.
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Print, stamp or type name of Notary Public
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