John Shubin/ Jerry BlairCity of Miami Beach Office of t~e City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
Emaih cityclerk@ci.miami-beach.fl.us
LOBBYZST REGZSTRATZON FORM
(City of Miami Beach, City Code Chapter 2, Division 3, Sectior~8~,~,t
o Check Box if an Amendment
NAME OF LOBBYIST: (Last)
BUSINESS ADDRESS: (Number and Street) (City) (State)
TELEPHONE NUMBER: FAX NUMBER:
(First) (M.[) DATE QUALIFIED AS LOBBYIST
(Zip Code)
EMAIL:
LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
BUSINESS ADDRESS: o_ .(Number and Street)
TELEPHONE'NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section if pflncipal is a Corporation, Partnership or Trust [Section 2-482 (c)]
· NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
· LIST ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP iNTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
Issue to be lobbied (Describe in detail):
III. cTrY AGENCIES/XNDIVZDUALS TO BE LOBBIED:
A) Full Name of Individual/TiUe B) Relationship
. DTSCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y~
FLAT RATE OR OTH£R~
A) LOBBYIST DISCLOSURE: ~ ~.~ ~.~ ~ t...- '-"/ / _~_ ~ ~ L.~ ~
B) PRJNCIP~.'S DISCLOSURE (OF LOBBYIST COMPENSATION): ~ ~- -% I t=~ &-.,-=.,--T /
Pursuant to Ordinance No. 2OO3-3393 Amendina Miami Beach City Code Chah~ter 2. Article VII. Division 5
Thereof EntiUed 'CamoaiQn Finance Reform' Via The Addition Of Code Section 2-~88 Entitled ~Prohibited
Camoaian Contributions Bv Lobbyists On Procurement Issues":
Are you Iobbvin= on a present or oendina bid for aoods, eeuiDment or services, or on a nresent
or oendine award for aoods, eeui=ment or service? [] Ye~No
Pursuant to Ordinance No. 2003-3395 Amendino Miami Beac/CiW~ode Chanter 2, Article VII Division 5
thereof Entitled 'C. amoaiQn Finance Reform'. Via The Addition Of COde~raection 2-490 Entitled "Prohibited
Camoaien Contributions By Lobbyists On Real Estate DeveloDment Issue~.'
Are you Iobbvine on a oendine aDelication for a Development Aareement with the City or
aDnli~ation for ch•nee of zonine mae desienation or chanae to the CitY's Future Land Use MaD?
[]yeSl C~l~l o
SIGNATURE UNDER OATH:
ON OCTOBER 1~ OF EACH YEAR, EACH LOBBYIST SHALL SUBHTr TO THE CTrY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDZI'URES TN THE CTTY OF ~ZAHT ,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:
VL LOBBYIST ZDENTZFZCATLON:
~ Produced ID '~rsonally Known
Form of Identification / ~, _
VII. SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK: ~.~.~ %. °?~.~_~b~
· . ,"
State o.f Florida, Sou.nb/.o.f ~,am,-Dade __ ~ /~,~:~,.,..~.;~U~s,~ /
Sworrt.[o aDO SUDSCriDeo~rore me
~ Si~nat r~ ~f Pub~ary - State o~ Flodda
Print, stamp or type name of Notary Public
Registration: ~CEFTED
If rejected, state reason:
Registration fee paid:~Yes [ ] No
"7/'~, '
DATA ENTRY DATE:
2nd Revision 3/18/03
FOR CLERK'S USE ONLY
] RF1ECTED DATE: [~'' '~ 0~'
[ ] Cash ~].-Check M~,~/
,2003 ENTERED By:L,/ ~c~. ~
F;\CLER\HATL\Lobbyists\registrationa03.doc
o ~7~2~/2003 M:22 30598~974
~UL-28-2003 ~ 11:~8 ~ ~I~IH & B~88 F~X NO, ~053818457'
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ON ocrol~ lin' OF EN::~ yELq, EAC~ LOISY3ST ~ SUBIG'T TO THE CITY CI. IERK AIi:lltEO
STAI'EH/INT UNDER Mm, USlY, NG WBIYING II~m~iOZ?Ul~ ~ TmIE C3~'Y OF mare ~ FOR
THE Ff~C:ED/NG CA&ENDMI. YI~IL
familiar with the provislor~ contained in section 2-462 of the Miata1 Beach OW Code ms amended, end ali
VZ, LOIhBT,--.I :EDWEaI.%CA~N~ ~
o Producx~d ZO .....
State cd' Florida, CotmW of Idtami-Oade. ·
Sworn b3 and au~ before me
p.~ s~mp or Lyp, nanm~ No~,, Po~rc