Alison Burgos / Women's Comm
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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 "Lobbyists" has specific exclusions. Please refer
to Ordinance 2004-3435.
NAME OF LOBBYIST:
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J (Last) (First)
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(Number and Street) (City)
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(M.I)
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TELEPHONE NUMBER:
qs'{- '17. '-/-0 070
FAX NUMBER:
M:c..",,; f)each H
(State)
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EMAlL:
'33/3'1
(Zip Code)
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I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAL/CLIENT:
,>').1 .4 N."
(City)
R j /J1":,,., .. te4c/' ;::1.- , 313'1
(State) (Zip Code)
apso,., <JW~MU)5CM"tV>V":+1f/J"cI....rJ
EMAIL: (Optional)
30'5-S3Z- ("'17
TELEPHONE NUMBER:
FAX NUMBER: (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. SPECIFIC LOBBY ISSUE:
Pre eIJto,-f,/" 0/
Issue to be lobbied (Describe in detail):
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(;7" rd/r.-prof,f everJ-I if) 200J:Ajvc..6-/;;
III. CIlY AGENCIES/INDIVIDUAL5 TO BE LOBBIED:
A) Full Name of Individual/TItle B) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
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B) PRINCIPAL'S DISCLOSURE (Of LOBBYIST COMPENSATION): (Required). Rf
1) Pursuant to Ordinance No. 2003-3393 Amendina Miami Beach City Code Chaoter 2. Article VII. Division 5
Thereof Entitled "Camoaian Finance Reform" Via The Addition Of COde Section 2-488 Entitled "Prohibited
Campaign Contributions By Lobbyists On Procurement Issues":
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Are YOU lobbvina on a Dresent or oendinG bid for Goods. eauiDment or services. or on a Dresent
or oendinG award for Goods. eQuiDment or service?
2) Pursuant to Ordinance No. 2003-3395 Amendina Miami Beach City Code Chaoter 2. Article VII Division 5
t.I1greQf. Entitled "Campaian Finance Reform", Via The Addition Of Code Section 2-490 Entitled "Prohibited
Camoaign Contributions By Lobbyists 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 em OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE
REPORTING PERIOD.
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Signature of Lo Ylst
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.
Signature of lobbyist: j(JL~ /,Bed in-
Signature of Principal/Client: ~~ ~''''-
VI.
LOBBYIST IDENTlFICATlON: PRINCIPAL IDENTlFICATlON:
Produced 10 17 frtJ /tC .1"3h,;;!;I~CotprodUCed ID
Form of Identification <70 ?- -0
Personally known (Lobbyist)
Form of Identification
Perso lIy known {Princip~
VII.
SIGNATURE AND STAMP OF NOTARY:
Signature of Public Notary - State of Florida
Notarization of Lobbyist's signature
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PAULA CALDeRON :
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FOR CLERK~NLY
Annual Registration fee: [ ] Yes [ NQ Amount Paid MCR It ~ - Date Paid
Lobbyist Registration form received and verified by: (
Revised 02/10/04 f: CLER\ALL\MA -M\LOBBYIST\LOBBYIST FORM 04