Steven Tebon City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed or ,,~;ned, whether paid or not, by a principal who seeks to encourage the pa~je, defeat
or modification of any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the
City Hanager or any city board or commiti~e; or any acUon, dedsio~ or recommende~on of any city personnel defined in any
manner in this section, during the time pertod of the entire dedslon-maklng p~ocess on such action, decision or recommendation
that f'ore~-~ably will be heard or reviewed by the dry commission, or a city board or committee. The term specifically Indudes the
principal as well as any employee engaged in lobbying activities. The ~ 'Lebbyi~ has ~ exdu~luns. Please refer
to O~llnanee 20~1.-3435,
NAME OF LOBBY]ST: (Last) (First) (M.I)
BUSINESS NANE AND ADDRESS (Nur~r and Street) (C~) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: EPtML:
LOBBYZS'I' RETAINED BY:
BUSINESS NAME AND ADDRESS} (Number and Stme~ (Crcy) (State) (ZIp Code) ~q ~'~,
TELEPHONE NUMBER: FAX NUMBER: (OpUonal) ENA[L: (Ol~Jonal)
Fill out this section if prim:il)al is a Corporation, Pa~nership or Trust [SecUon 2-482 (c)]
· NAME OF CHIEF OFFICER, PARTNER, OR BENEFZCZARY:
· [DENT]FY ALL PERSONS HOLDTNG, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORA'I'[ON, PARTNERSHIP OR TRUST:
SPECIFIC LOBBY ISSUE:
Issue to'be lobbied (Describe in detail):
ZZX. Ct"TY AGENC1ES/tNDZIR[DUALS TO BE LOBBZED:
A) Full Nam of Zndividual/TJife
B) Any Finandal, Familial or Profeaslonal Relationsl~
~ C.~
rtl
DXSCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSA'rJON (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (R~quJr~J) N /~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION); (Req~lred), ~ I '
~imbumement. Pursuant to Ordinance N~. :2004-3435.
1) P,,rs,,a~L to Ordi~_-__,~,~ Ne. __~9P_~339~ Amendine Miami Beach Otv Code C~aoter 2. Article VII. Division
Thereof E .r!~* ~ 'Can~ai~n Finance Reform~ Via The Adcl~don Of Code Secl~n 2-~88 E~l~ded ~Pmhibited
/'~No: ~ Are you ~__h~vin= on n nresent or ~ ~ hr ~ ~ui~ or ~ or on a ~
Ym
~ ~i~ ~ ~r a~ ~ui~ ~ ~?
2) ~muant ~ O~im~ No. ~3~5 ~di~ M~ ~ ~ ~ ~ 2. ~ ~ ~n 5
~ En~ '~m~n Rna~ R~", V~ ~ ~ ~ ~ ~ 2~ ~ ~i~
~m~ ~n~ns ~ ~ ~ On ~1 ~ ~1~
SZG~TU~ UNDER OATH:
ON OCTOBER IsT OF EACH YEAR, EACH
STATEMENT UNDER OATH, l/Sl/NG
RECEI'VED, XN THE CI'TY OF f4XAMX BEACH
SHALL BE FXL.ED EVEN XF THERE HAVE BEEN NO
CLERK A SXGNED
AS CONPENSATXON
YEAR. A STATEMENT
DUI~TNG THE
! do solemnly swear
familiar with the
requirements.
the and
and that I have read or am
City Code and all reporting
Signature
Signature of Prlncipa
v~.
PI~NCXPAL IDENT~I~CAT~ON:
Produced ID
Form of Identification
Personally known (I.obbyi~t)
VII. SZGNATURE AND STAMP OF NOTARY:
St~e of Florida, County of Miami-Oade
Sworn to and subscribed before me
This day of ,20_
Signature of Public Notary - State of florida
NotarizaUon of Lobbyist's signature
[] Prcx~ ID
Form of Identification
~J ~.Permnally known (Prindpal)
State of florida, County of Miami-Dade
Swom and subsotbed before me
Lobbyist Regb,b;.~on Form rec~elved and verified by: .q'?]~ [~U~..~ -- -BBY/-- FORM 04
Revlsed02/lO/04 F: CLER~ad.L\ MARIA- M\LOBBY~.LUI:~ bi