Ilana Cohen
City of Miami Beach Office of the City Oerk
1700 Convention Center Drive, Miami Beach, FL 33139
Email: cltyclerk@Cl.miami-beach.n.U5
LOBBYIST REGISTRATION FORM
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02
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<[:::0\,:3 OFF ICE
(City of Miami Beach, City Code Chapter 2, Division 3, Section 2-4B1)
a Check Box If an Amendment
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(Number and Street)
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(M.!) DATE QUAUFIED AS LOBBYIST
IlP<7
(Zip Code)
30 C; . J2.12.~' 10 to & ()
TELEPHONE NUMBER:
FAX NUMBER:
EMAIL:
I. LOBBYIST RETAINED BY:
I LA NA- c..o I-t E 1J
NAME OF PRINOPAL/CUENT:
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BUSINESS ADDRESS:
COLLI }J So Avr;
(Number and Street)
l\~/A-MI ~t FL
(City) (State)
3313 i
(Zip Code)
~OIS fa 12 -- 30()'J-
TELEPHONE NUMBER:!
FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill out this section If prlndp.1 Is. Corporation, Partnership or Trust [SectIon 2-482 (c)]
. NAME OF CHIEF OFFICER, PARTNER, OR BENEFIOARY:
. UST ALL PERSONS HOLDING, DIRECTlY OR INDIRECTlY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
U. SPEaFle LOBBY ISSUE:
'lID c..C)(..Lt ~S IAVr;..
Issue to be lobbied (Desalbe In detail):
III. CITY AGENaES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Relationship
C,"{\/ OF fJ1/AM\ Be! C H
,
,
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSAnON (DISCLOSE WHETHER HOURL Y,
FlAT RA TE OR OTHER).
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A) LOBBYIST DISCLOSURE: g atO
~A_
F?f't '
B) PRlNOPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):<14 % (J() rtf. l2lZb cJ r CT
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 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 Section 2-482 of the Miami Beach City Code as amended, and all
reporting requirements.
Signature of Principal/aient: .
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LOBBYIST IDENTlFlCAnON: I:: D L .t:\=- n Co a't) __ 2-l3 ~ s--8 - 2-1f f - 0
~ Produced ID FDL.- c.. S-oo - 'foo - (.'~ - c.. i~ ' 0
Form of Identificatlon
Signature of Lobbyist:
VI.
o Personally Known
VII. SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This \ -.:, day of 1'1"" eM L-.V: 2002.
Sig ature of Public otary - State of Florida
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Print, stamp or type name of Notary Public
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LILLIAN BEAUCHAMP
NOTARY PUBLIC STATE OF FLORIDA
COMMISSION NO. DDl09289
MYCO~': '.~-'''NEXP. APR. 29
FOR CLERK'S USE ONLY
Registration:
[ ~CCEPTED
[ ) REJECTED
DATE:
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If rejected, state reason: /
Registration fee paid: M'jeS [ ) No ^
[vf Cash [ ] Check MCR # . t-..
pATA ENTRY DATE: .lL\ z....-i ~. 2002
I First RevIsion - 05/17/02