Nancy Terminello/Peter Pekofsky
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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 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 decision-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 term ftLobbyists" has specific exclusions. Please refer
to Ordinance 2004-3435.
Tpnnin@llo
NAME OF LOBBYIST:
(Last)
Nancy
(First)
C.
(M.I)
Terminello & Terminello, P.A. 2700 SW 37th Avenue Mi_i, FL 33133
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 444-5002
TELEPHONE NUMBER:
(305) 448-5566
FAX NUMBER:
NancY@Terminello.com
EMAIL:
I. LOBBYIST RETAINED BY:
Peter Pekofsky, President
NAME OF PRINCIPAl./CUENT:
Club Deep, Inc.
BUSINESS NAME AND ADDRESS
621-623 Washington Avenue Miami Beach, FL 33139
(Number and Street)
(City)
(State)
(Zip Code)
(305) 532-1509
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:
. IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPEOFIC LOBBY ISSUE:
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
I .
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,
FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
$ln.nnn nn
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
o Yes UNo: Are vou reDresentina a not-for-Drofit corDoration or entity without sDecial comDensation or
reimbursement. Pursuant to Ordinance No. 2004-3435.
$10.000.00
1)
Pursuant to Ordinance No. 2003-3393 Amendina Miami Beach Citv Code Chaoter 2. Article VII. Division 5
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 vou lobbvina 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 Citv Code Chaoter 2. Article VII Division 5
thereof Entitled "Camoaian Finance Reform". Via The Addition Of Code Section 2-490 Entitled "Prohibited
Camoaian Contributions Bv Lobbvists On Real Estate Develooment Issues":
OY~No:
Are vou lobbvina on a Dendina aDDlication for a DeveloDment Aareement with the City or
implication for chanae of zoning maD desianation or chanae to the City's Future Land Use MaD?
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 CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE
REPORnOGPERIDD. ~d.-- ~
Sig ture of Lobbyist
Signature of Principal/Client:
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 and all reporting
requirements. )f~ . h.- >
Signature of Lobbyist: - ~
/t- /? ~
I /
PRINCIPAL IDENTIFICATION:
o Produced ID ~ L V.L P d. \ a l, --, (." "" ')
Form of Identification
o d "0-0
VI.
LOBBYIST IDENTIFICATION:
[! Prod uced ID
Form of Identification
~rSOnallY known (Lobbyist)
[] Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
Signatur
Notariz
State of Florida, County of Miami-Da1e
Sworn ilnd subscribe fer: me Ll
This ~da of f1 1 , 20Q., I
~a\. Maria Piroto
'\~ ,; My Commission CC986897
'" "df Expires December 1 O. 2004
FOR CLERK'S U5.E ONLY #- )
Annual Registration fee: [ ] Yes [ ] No A u Pai . Ol.) MCR # Z-Icd" tJ~< Date Paid 2..i) uf
Lobbyist Registration Form received and verified by. I
Revised 02/10/04 F: C L\MARIA-M\LOBBYIST\LOBBYIST FORM 04