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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 pr1ndpaJ who seeks to encourage the passage, defeat
or modification of any ordinance, resolution, action or decision of any c:ornrTIissIOne; any action, decision, recommendation of the
Oty Manager or any dty board or committee; or any action, decision or recommendation of any dty personnel defined in any
manner in this section, during the time period of the entire decIsIon-mak1n9 process on such action, decision or recommendation
that toreseeably will be heard or reviewed by the dty commission,. or a city board or committee. The tenn specifically includes the
principal as well as any emplOyee engaged in lobbying activities. The tenn "lobbyists- has specific exdusions. Please refer
to Ordinance 2004-3435.
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t\ f\{(..<\<- \S,O N
NAME OF LOBBYIST: (Last) (First) (M.I)
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BUSINESS NAME AND ADDRESS (Number and Street) (Oty) . (State) (Zip Code)
-30S - 5 ::a.-oSCD ?:DS -5,31 - b I S () t<tt 12b5.f>o:>f:Etl.sOllTt( ,('1 q-
TElEPHONE NUMBER: FAX NUMBER: EMAIL:
I.
LOBBYIST RETAINED BY:
~
F~A~-'- Ft-O(.?"ENT1N6 '-?~f=SlOCN\
NAME OF PRINOPAl./WENT: \500 oc.E..f\'N 'W-\IJE- f'J~OyV\ \ ~\UM f\SSoe., /~
M \ (\-(\1\\ B<i AC\1, \=L 33\39
(Number and Street) (Oty) (State)
3lY5~-S3'-f~ R-l/bS(r)
FAX NUMBER: (Optional)
BUSINESS NAME AND ADDRESS
(Zip Code)
\
1
~535-814b(tf)
TELEPHONE NUMBER:
EMAIL: (Optional)
Fill out this section If prindpal is a Corporation, Partnership or TI1ISt [Section 2-482 (e)l
.
NAME OF CHIEF OFFICER, PAflTNER, OR BENEFIOARY:
FX2-f\NV- t=l6~f "",f'J 0 - ?f.2..~$'1 'DFN\
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IDENTIFY ALL PERSONS HOLDING, DIRECTlY OR INDIRECTLY, A S% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
N o,JE
.
.
II. SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (DescrIbe In detail):
III. CITY AGENClES/INDMDUALS TO BE LOBBIED:
I\Jb1S'~ T ~~...rC~~\f\\\'.l~~ tJ\ ::t:'-?50CS
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A) Full Name of Indlvidual/Tltie
B) Any financial, Familial or Professional Relationship
t1-ANl-H N '- \30 A. ~ t>
Cll Ca M M ,"551 CH-J
t>(A NtJl N G- STA"\'.-f
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLA T RA TE OR OTHER). "-# 00 e:P /
A) LOBBYIST DISCLOSURE: (Required) DO 0 . 8' f\l Nt \2- ~ 3 . / f-b J (L
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (ReqUlred)* .OOOC:::> ((E ,,,,,tfl- ..tt '3 75,~o . U~
D Yes ~o: Are you reDresentinG a not-for-Drofit corDOration or entity without soecial comoensation or
reimbursement. Pursuant to Ordinance No. 2004-3435.
1)
purs:~t ~ ~~i~nce No. 2003-3393 Amendina Miami Beach City Code Chaoter 2. Article VII. Division 5
Ther E ti "~~ian Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited
Camoai(;Jn Contributions Bv lobbyists On Procurement Issues":
D Yes ~o:
Are YOU lobbyinG on a Dresent or oendinG bid for Goods. eauiDment or services. or on a Dresent
or oendinG award for GOods. eauiDment or service?
2)
purs:nt t~ ~inance No. 2003-3395 Amendina Miami Beach City Code Chaoter 2. Article VII Division 5
ther f En itl "Campaian Finance Reform". Via The Addition Of Code Section 2-490 Entitled "Prohibited
Cam:n::~ns: ~:i::' Rea~:~ ::m:, ;es.: .
Are I bb I G n a e dl G D heat a OD e AGreement With the City or
ap~li~ti~n for chanGe of zoninG maD desiGnation or chanGe to the City's Future Land Use MaD?
DYes L:
v.
SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHAll SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, UmNG LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR TH PRECEDING CALENDAR YEAR. A STATEMENT
SHAll BE FILED EVEN IF THERE HAVE BEEN PEND ES 0 MPENSA110N DURING THE
REPORTING PERIOD.
Signature of Lobbyist
I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am
familiar with the provisl c ntalned i Sectio - 2 of the Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist:
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VI. LOBBYIST IDENTIFICATION:
o Produced ID
o Produced ID
Form of Identification
~rSOnallY known (Lobbyist)
Form of Identification
~sonally known (Principal)
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State of Florida, County of Mi~i-D~8c;SION c.":" ~
~ .;..~: ..,.-..0. ~
Sworn a~ subscribed befor~e..~~~,..~er 14,<"a~". ';:
This~dayof \un€- :. ~-$ ~(fl ~*:
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Signature of Public Notary - . :~~'\'vi'
Notarization of Prindpal's st7.t~~,.ec.~~,~ &:..,~~
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VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This day of .20_
Signature of Public Notary - State of Florida
Notarization of Lobbyist's signature
_"._ --,- FOR CL
Annual Registration fee: [---1"Yes [ ] No Arno nt P .
Lobbyist Registration Form received and verified by:
Revised 02/10/04 F:
~SEONLY
€ MCR It;) 77 r'1 Date Paid