Bruce Orosz/ACT Productions 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 retained, whether paid or not, by a principal who seeks to encourage the passage, defeat
or modification of any ordinance, resolution, action or derision of any commissioner; any action, decision, recommendation of the
City Manager or any dty board or committee; or any action, decision or recommendation of any city personnel defined in any
manner in this section, during the time period of the entire decision-making process on such action, decision or recommendation
that foreseeably will be heard or reviewed by the dty commission, or a city board or committee. The term spedfically includes the
prindpal as well as any employee engaged/nlobbying activities. The term 'Lobbyi~t~" has specific exclusions, Please refer
to Ordinance 2004-3435.
NAME OF LOBBYIST: , ~ (Last) (First)
/ / !
BUSINg. SS NAME AND ADDRESS (Number and Street) (City) /~ (State) (Zip Code)
TELEPHONE NUMBER: 'FAX NUMBER: EMA~L:
I. LOBBY~SI' RETAZ.NE~./~) BY:
NAME OF PRINCIPAL/CLIENT:
~)~g'~__i ~ .--~ ) (Number a~d Street) (Ci~) . (State) (Zip Code)
'I'ELEPRONE NUMBER; ~ ' FAX NUMBER: (Optional) EMA~L![: (Optional)
Fill out this section if principal is a Corporation, Partnership or 1'.rust [Section 2-482 (c)]
· NAME OF CHIEF OFFICER, PARTNER, OR BENEFIC~ARY: '~,~0 C ~
· IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST: ~
II. SPECIFIC LOBBY~SSU~:
Issue to be lobbied (Describe in detail): :::Y,. ,,,
III. ClTY AGENCIES/INDZVZDUALS TO BE LOBBIED: c:) ~
-fl ~ ~
A) Full Name of Zndlvidual/TiUe 'lB)'Any Financial, Familial or Prefesslonal I~tia~ir~hip
q,
DTSCLOSURE OF TERMS AND AMOUNTS OF LOBBY[ST COMPENSATrON (DZSCLOSE WHETHER
FLAT RATE OR OTHER~
A) LOBBYIST DISCLOSURE: (Required) I~'~ ~ v,,- ,~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
[] Yes F~Ol Are YOU reoresentinu a not-for-orefit corooration or entity without soecial ~m~en$~tipn
reimbursement. Pursuant to Ordinance No. 2004-3435.
1)
Pursuant to Ordinance No. 2003-3393 AmendinQ Miami Beach City Code ChaDter 2, Article VII, Division
Thereof Entitled "CamDaiQn Finance Reform" Via The Addition Of Code Section 2-4~$ Entitled "Prohib!ted
CamoaiQn Contributions By Lobbyists On Procurement Tssues':
Are you Iobbvino on a oresent or Dendina bid for aoods, eouiDment or service~: or on a present
or Dendino award for uoods, eDuioment pr service?
Pursuant tO Ordinance No. 2003-3395 Amendinq Miami Beach City Code Chapter 2, Article VZ! Division
thereof Entitled "CamDaiQn Finance Reform", Via The Addition Of Code Section 2-490 Entitled "Prohibited
Camoaien Contributions By Lobbyists On Real Estate Development issues":
Are you IobbvinD on a uendina auDlication for a Develooment Aureement with the City or
application for chanoe of zoninu mad desianaUon or chanue to the City's Future Land Use Map?
V. SIGNATURE UNDER OATH:
ON OCTOBER IsT OF EACH YEAR, EACH LOBBYZST SHALL SUBMTF TO THE CTI'Y CLERK A/SZGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDTrURES, AS WELL AS COM.P~NSAT~ON
RECETVED, ZN THE C~TY OF MTAM! BEACH FOR THE PRECEDZNG CALENDAR YEAR· A//STATEMENT
SHALL BE FTLED EVEN I'F THERE HAVE BEEN NO EXPENDTrURES ~r"/COMPENSATTO~I' DURING THE
REPORTTNG PER~OD.
/~r;~f Lobbyist /
! do solemnly swear that all of the foregoing facts are true/~nd c~rrect and tha~read or am
familiar with the provisions contained in Section 2-482 of the(.Miami Be_,~eh City Cod,e/and all reporting
requirements.
Signature of Lobbyist:
· O": PRt NC'~IIL I'DEI~ ~I'ZON: /)
U Produced [D [] Produced tD '--'
Form of Tdentification Form of ]Identification
i,r'~ersonally known (Lobbyist) ~onally known (Principal)
V~T. SZGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dude State of Florida, County of Miami-Dade
Sworn tO a~d subscribed before~me , / Sworn and subscribed before me .~
This _ ~* sT _day/~f f"~f'r' L.., 20___0 ~-/ This ~-- day of /L/~_/~*}~._, 20 0~
~ig~ature of Public Nota~ - Stat~f Flori~ ~.';~6s~ ..O ~nature ~ P~blic No~ - State of Florida
t~ rization of Lobbyi~i~atu re ~ ~,, ~, ;~ ~arizat~o~ of Principal~ signature
...
FOR ~E~'S USE ONLY ' b-- ''-
Annua1Registrationfee:~Yes[ ]No AmountPaid [~,0~ ~CR~ ~ ~0~ DatePaid~-~-~
Lobbyi~ Registra~on Form received and verifi~ by: ~ '
Rev ~d 02/10/04 F: CLE~LL~N~I~LOBBY~ FORM ~