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03 t~PR 30 PM z: 52
CLERK-S Off \CE
City of Miami Beach Office of the City Clerk r IT 't'
1700 Convention Center Drive, Miami Bach, FL 3313!g \ I
Email: cityclerk@cLmiami-beach.fl.us
LOBBYIST REGISTRATION FORM
(City of Miami Beach, City Code Chapter 2, Division 3, Section 2-481)
o ~ Check Box if an Amendment
NAME OF LOBBYIST:
Bercaw
(Last)
Jeffrev
(First)
(M.I.) DATE QUALIFIED AS LOBBYIST
200 S. BISCAYNE BLVD.. SUITE 850
BUSINESS ADDRESS: (Number and Street)
Miami
(City)
Florida
(State)
(305) 377-6220
TELEPHONE NUMBER:
(305) 377-6222
FAX NUMBER:
I.
LOBBYIST RETAINED BY:
Narcisse
NAME OF PRINCIPAUCLlENT:
710 North Clark Street
BUSINESS ADDRESS: (Number and Street)
Chicaao.
(City)
Illinois
(State)
(312) 787-2675
TELEPHONE NUMBER:
(312) 787-0128
FAX NUMBER: (Optional)
EMAIL:
~
33131
(Zip Code)
60610
(Zip Code)
Fill out this section if principal is a Corporation, Partnership, or Trust [Section 2-482 (c)]
EMAIL: (Optional)
? NAME OF CHIEF OFFICER, PARTNER OF BENEFICIARY:
Jay Vohra
? LIST ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST
IN SUCH CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
Administrative Aoorovals and Conditional use oermits
Issue to be lobbied (Describe in detail):
III. CITY AGENCIESIINDIVIDUALS TO BE LOBBIED:
A) Full Name of IndividuallTitle
City of Miami Beach Plannina Board
NONE
B) Relationship
.,
..
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATRION (DISCLOSE WHETHER
HOURL Y, FLA T RA TE OR OTHER): /'
A) LOBBYIST DISCLOSURE: Hourlv U..DlJ _~,. ..
I
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIEST COMPENSATfON):
Houri
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
PRESEDING 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/Client:
VI. LOBBYIST IDENTIFICATION:
o ~ Produced I D
Form of Identification
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 2'1 day of tJ by',- f , 2003.
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Signature 0
Print, stamp or type name of Notary Public
FOR CLERK'S USE ONLY
Registration: ~ACCEPTED [] REJECTED DATE: l.{-30 ~G3
If rejected, state reason:
Registration fee paid~h[ ~oCheck~CR # ~~ l~
pATA ENTRY DATE: 72OU2' ENTERED BY: _
1 First Revision - 05-17-02
. IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER):
A) LOBBYIST DISClOSURE:
B) PRINCPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
V. SIGNATURE UNDER OATH:
ON OCTOBER lIT 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 contained in Section 2-482 of the Miami Beach City Code as amended, and all
reporting requirements.
Signature of LObbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
CJ Produced ID
o Personally Known
Form of Identiftcation
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 . 2003.
Signature of Public Notary - State of Florida
1
Print, stamp or type name of Notary Public
Registration: [] ACCEPTED
\
FOR CLER~'S USE ONLY
\
[ ] REJECTED DATE:
If rejected, state reason:
RegIstration fee paid: [ ] Yes [ ] No [ ] Cash [ ] Check MCR #
DATA ENTRY DATE:
. 2003 ENTERED BY:
2nd Revision 1/27/03
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