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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 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 "LobbyistsN has specific exclusions. Please refer to Ordinance 2004-3435.
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NAME OF LOBBYIST: (Last).
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BUSINESS NAME AND ADDRESS (Number and Street) (City)
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TELEPHONE NUMBER: FAX NUMBER:
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(State)
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(Zip Code)
EMAIL:
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(State) (Zip Code)
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAl/CLIENT:
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TELEPHONE NUMBER: FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or trust [Section 2-482 (c)l
· 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:
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Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
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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 COMPENSATI N (DISCLOSE WHETHER HOURL Y,
FLAT RA TE OR OTHER): ~
A) LOBBYIST DISCLOSURE: (Required) .~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues";
ment or services or on a
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues";
3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of
"lobbyist" as set forth in Section 2-481. above) who only appears as a representative of a not-for-profit
corporation or entity without special compensation or reimbursement for the appearance, whether direct, or
indirect, to express support of or opposition to any item, shall register with the clerk as required by this
se ion but, shall not be required to pay any registration fees..
V. SIGNATURE UNDER OATH:
I do solemnly swear that
familiar with the provisions c
requirements.
Signature of LObbYist~
Signature of Principal/Client:
1/
nd correct and that I have read or am
'ami Beach City Code and all reporting
VI.
o Produced ID
Form of Identification
~nallY known (Lobbyist)
o Produced ID
~ Form of Identification
~rsonallY known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
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Date Paid
Revised 12/08/04