Robert Fine/Altos del MarOty of M,am, Beach Office of the Oty Clerk
1700 Convention Center Drive, Miami Beach, FL 331
Emaih cityderk@ci.miami -beach.fl. us
LOBBYTST REGZSTRATI'ON FORM
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(city of Miam~ Beach, City Code Chapter 2, Div~s~
~ Check Box it an Amendment
NAME OF LOBBYIST: (Last) (First)
BUSINESS ADDRESS: (Number and Street)
TELEPHONE NUMBER:
(M.I) DATE QUALIFIED AS LOBBYIST
(City) ~ (State) (Zip Code)
F~ NUMBER: EMIL:
I. LOBBYZST RETATNED BY:
NAME OF PRINCIPAL/CLIENT:
BUSINESS ADDRESS: (Number and Street) (City) (State)
(Zip Code)
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 OFFICER, PARTNER, OR BENEF[OARY:
· LIST ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREffrl~ SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
Issue to be lobbied (Describe in detail):
III, CITY AGENCIES/INDZVZDUALS TO BE LOBBIED:
A) Full Name of Individual/TiUe
B) Relationship
FLA T RA TE OR OTHER):
A) LOBBYIST DISC,OSURE:
UI~I.I.I,J;~UKI' ur I I"KPID ~IIU FiPIt,,/UI~I I D ur I. UDD! I;~ I t,.,t./PII'I'I1;3~Ili 111,./11 [.UI~t,~I.,I./DI' WIlE I Ilr'K /'/~/U/(/.. I'!
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
1)
Pursuant to Ordinance No. 2003-3393 Amendinq Miami Beach City Code Chapter 2, Article VII, Division 5
Thereof Entitled "Campaiqn Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited
Campaiqn Contributions By Lobbyists On Procurement Issues":
2)
Are you Iobbyin.q on a present or pending bid for qoods, equipment or services, or on a present
or pendinq award for qoods, equipment or service? Yes ~
Pursuant to Ordinance No. 2003-3395 Amendinq Miami Beach City Code Chapter 2, Article VI! Division 5
thereof Entitled "Campaiqn Finance Reform", Via The Addition Of Code Section 2-490 Entitled "Prohibited
Campaiqn Contributions By Lobbyists On Real Estate Development Issues":
Are you Iobbyinq on a pendin.q application for a Development A.qreement with the City or
applicat'_~u~'fl)r chanqe of zoninq map desiqnation or change to the City's Future Land Use Hap?
Yes
V. SIGNATURE UNDER OATH:
ON OCTOBER IsT OF EACH YEAR, EACH LOBBYIST SHALL SUBMI'r TO THE cTrY CLERK A SIGNED
STATEMENT UNDER OATH, LTSTTNG LOBBYTNG EXPENDI'rURES TN THE CITY OF MTAIqT BEACH FOR
THE PRECEDTNG 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 Lobbyist:
Signature of Principal/C
VL
LOBBYZ~I'
Personally Known
~ Produced ID t-t GS~ --OOO- ~,ai- old 3-
Form of Identification
SIGNATURE AND b-I'AI~IP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade
Sworn _~o~d subscribe,~l~efore me
This ~ day of//[~~.~ , 2003.
Signaye of I:fu.~.~o~r~~l~~~~rida
Print, stamp or type name of Notary Public
Registration: [:~...ACCEPTED
If rejected, state reason:
Registration fee paid: .~/e.s ~[ ]
DATA ENTRY DATE:
2nd Revision 3/18/03
FOR CLERK'S USE ONLY
No
[ )Cash ~::TCheck MCR # t ~ ~'0 / (0
,2003 ENTERED BY: ~
"~: \~HATL\Lobbyists\registrationa 03.doc