Mai Nguyen & Hoa Ngoc NguyenCity of Miami Beach Office of the City aerk
1700 Convention Center Drive, Miami Beach, FL 33139
Email: cityderk@d .mia mi-beach.fl .us
LOBBYIST REGISTRATION FORM
(Oty of Miami Beach, City Code Chapter 2, Division 3, Section 2-~81)
ca Check Box if an Amendment
NAME OF LOBBYIST: (Last)
BUSINESS ADDRESS: (Number and Street)
TELEPHONE NUMBER:
RECEIVED
03 NOV -'/ AH 9:26
CITY CLERK'S OFFICE
(First)
(M.I) DATE QUALIFIED AS LOBBYIST
(C~ty) (State) (Zip Code) ~.~
FAX NUMBER: E'~AIL:
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/OcI~NT: ~
BUSINESS ADDRESS: (Number ~ ~-treet)
(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 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):
IZX. cTrY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Relationship
DISCLOSURE OF TERMS AND AMOUNTS OF LOBBY]ST COMPENSATION (DISCLOSE WHETHER HOUR£ ~
FLAT RATE OR O THER~
B) PR~NC:[PAL'$DJSCLOSURE(OFLOBBYJSTCOMPENSAI'[ON): ~L~[~.C-'~,~'''~) '~. ~*/'~(_~_._
1)
2)
Pursuant to Ordinance No. 2003-3393 Amendina Hiami Beach City Code Chapter 2. Article V~Z. Division 5
Thereof Entitled ~Camoaian Finance Reform" Via The Addition Of Code Section 2-488 Entitled 'Prohibited
Camoaien Contributions By Lobbyists On Procurement Issues":
· . In . ? Y
Pursuant to Ordinance No. 2003-3395 Amendine Miami Beach City Code Chapter 2. Article VII Division 5
thereof Entitled 'Camoaian Finance Reform". Via The Addition Of Code Section 2-490 Entitled "Prohibited
Camoaien Contributions Bv Lobbyists On Real Estate Develooment Issues":
Are you Iobbvina on a aendina application for a DeveloPment Aareement with the City or
aDDliCatioh for chanae of ;onina mau d~;~nation or chanae to the City's Future Land Use HaD?
aYes
V. SZGNATURE UNDER OATH:
ON OCTOBER 1s*r OF EACH YEAR, EACH LOBBYIST SHALL SUBMII' TO THE CITY CLERK A SIGNED
· STATEHENT UNDER OATH, LZS1/NG LOBBYING EXPENDI'TURES IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR.
Signature of Principal/aient:
I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am
familiar with the provisions contained in Section 2-482 of the Miami Beach City Code as amended, and all
reporting requirements. ?//
LOBBYZST XDENTZFZCATZON:
Produced ID
Form of Identification
[] Personally Known
VII, SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This ~ day of IL~C:~. .2003.
Signature of Public Notary - State of Flodda
Registration: ~ ACCEPTED
If rejected, state mason:
RegistraUon fee paid: ~f,,~Yes [ ] No
DATA ENTRY DATE: /J ~' { -"~.
2nd Revision 3/18/03
~~sh~?$ :.ofJNotary Public
[ ] RE3ECTED DATE:
F:\CJ.ER~2.ATL\Lobbyists\registrationa03.doc