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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 3:et3@'R I 3 ~H II: 51
LOBBYIST REGISTRATION FORM CITY CLE\\K'S OFF ICE
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 decision of any commissioner; any action, decision, recommendation of the
City Manager or any city 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 dedsion-making process on such action, decision or recommendation
that foreseeably will be heard or reviewed by the city commission, or a city board or committee. The term specifically includes the
principal as well as any employee engaged in lobbying activities. The tenn ~Lobbylsts" has specific exciuslons. Please refer
to Ordinance 2004-3435.
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NAME OF LOBBYIST: (Last) ~ ~I ?i~ ~ ~ (M.!)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) " (Zip Code)
~p(' 974" t-~-Z2- 'je;)' ~Z;4-' Z$jo /fP1(/7"al!re./7p~~'c.~'"
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAljCUENT:
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BUSINESS NAM AND ADDRESS
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TELEPHONE NUMBER:
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(Number and Str) (City)
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FAX NUMBER: (Optional)
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EMAIL: (Optional)
Fill out this section If principal is a Corporation, Parb1ership or Trust [Section 2-482 (c)]
. NAME OF CHIEF OFACER, PARTNER, OR BENEACIARY:
. IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A S% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
III. cnv AGENCIES/INDMDUALS TO BE LOBBIED:
A} Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLA T RA TE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) fr((tt;cJ ~/~/I/ ~ --
. ,
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
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1)
Pursuant to Ordinance No. 2003-3393 Amendina Miami Beach City Code Chaoter 2. Article VII. Division S
Thereof Entitled "Camoaian Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited
Camoaian Contributions Bv Lobbvists On Procurement Issues":
o Yes ~o:
,
Are YOU lobbyina on a Dresent or Dendina bid for aoods. eauiDment or services. or on a Dresent
or Dendina award for aoods. eauiDment or service?
2)
Pursuant to Ordinance No. 2003-3395 Amendina Miami Beach City Code Chaoter 2. Article VII Division S
thereof Entitled "Camoaian Finance Reform". Via The Addition Of Code Section 2-490 Entitled "Prohibited
,Camoaian Contributions Bv Lobbvists On Real Estate Develooment Issues":
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, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CAL DAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO P DIT RE 0 PENSATION DURING THE
REPORTING PERIOD.
I do solemnly swear that all of the
familiar with the provisions cont in
requirements.
regoing facts are true and correct and that I have read or am
in Se io 2 f the Miami Beach City Code and all reporting
Signature of Lobbyist:
Signature of prin~i aI/Client:
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VI. ~P...~i-r DENTIFICATION:
IJ troduced ID
j n Form of Identification
Li Personally known (~L.jiltl.ll
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VII. IGNATUR ND STAMP OF NOTARY:
o Produced ID
Form of Identification
o Personally known (PrillliIllBI) L"O(!,f],/ ~Jr
State of Florida, County of Miami-Dade
Sworn ~bscribed before me
This ~ay of , 2
Signatur f Public Notary State 0
Notarization of Principal's signa
I
C
JOSIl BARDIN JR
NOTARY PUBUC STATE OF FLORIDA
COMMISSION NO. 00117885
MY COMMISSION EXP. MAY 14,2006
USE ONLY fool L Or;
0,- MCR#^~IQ()b
Date Paid Lf- t'O '-0 t.r-
YIST\LOBBYIST FORM 04