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City of Miami Beacfi Officee>)ll(1l1:! C3i1w Clerk
1700 Convention ceater.';lltl~~~~~'llWT~lh, FL 33139
LOBBYIST REGISTRATION FORM
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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 tenn "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
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NAME OF lOBBYIST: (Last) (First)
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BUSINESS AME AND ADDRESS (Number and Street) (City)
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FAX NUMBER:
(M.!)
VIVLA&:.. $/v;{ :;Fd::r;).... Lo~ A.JeYl<.r, C4
(State) (Zip Code) rOO J.J'
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EMAIL:
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TELEPHONE NUMBER:
I. LOBBYIST RETAINED BY:
Fox Ptl/t f).""tr,'cC{() JptJr+~
NAME OF PRINOPAljCUENT: .
(F.P. A.S. ')
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BUSINESS NAME AND ADDRESS
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TELEPHONE NUMBER:
12A. St t9-o 0
(Number and Street)
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( City)
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FAX NUMBER: (Optional)
FL 33n6S
(State) (Zip Code)
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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:
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· IDENTIFY All PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
Issue to be lobbied (Describe in detail):
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III. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
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Con veil +; 0/1 flu-lf" or} Iv
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLA T RA TE OR OTHER):
. A)' (.oBBYIST DISCLOSURE: (Required)
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IV,' .I A
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). L Ii
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":
o Yes ~ Are yOU lobbvinG on a Dresent or Dendina bid for Goods. eauiDment or services. or on a
Dresent or DendinG award for aC?ods~ eauiDment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
DYes ~ Are YOU lobbylna on a oendlna aoolication for a Develooment A9reement with the City or
aDDlication for chanae of zoninG maD desiGnation or chanGe to the City's Future Land Use
MaD? .
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
section but, shall not be required to pay any registration fees..
o Yes ~ Are you rep.resentl"" a not-for-profit corooration or entity without soecial com~nsation
or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH' YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, USTING 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"N, O~, RES 0, R c:rez:, 5 ON DU,RING THE
REPORTING PERIOD. .,' ./~ ~.
'i.., , Signature of t'obbyist
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. ....-J :/ ~ ~.
ignature of Lobbyist: ~--.'
LOBBYIST IDENTIFICA
IDENTIFICATION:
o Produced ID
I Form of Identification
Personally known (Lobbyist)
o Produced ID
Form of Identification
"rsonallY known (Principal)
SIGNATURE AND STAMP OF NOTARY:
Srgoatuce of Publi Not ry - S of Florida
NO~ritation of Lobb ist's signature
Signature of Public Notary Sta
Notarization of Principal's si
r:-- FOR CLER!r~ USE ONLY
Annual Registration fee: [.A Yes [ ] No Amount Paid ~ ~ MCR # ~lo Date Paid ~~
Lobbyist Registration Fornf're~eived and verified bY:L ~~
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM OS.doc Revised 12/08/04