Adrian Raymond Hisp. Center
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<9 MIAMIBEACH ~f:rc
City of Miami Beach Office of the ci~<;:le-;k'" l.1 V E D
1700 Convention Center Drive, Miami Beach, FL ~,~ 2 9 Pi~ii '-4: 43
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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 lob~ activities. The tenn 'Lobbyists" has spedfic exclusions. Please refer to Ordinance 2004-3435.
NAMEOFlC>..j~vV1 r0j)fL'I\N (First) 1 d,MIl
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BUSI ESS NAM ND ADDRESS (Number and St et) (City) (State) (Zip Code)
807- DOS C'3oS gG7 ,--oos L QADf2/~Z~AOl
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LOBBYIST REGISTRATION FORM
FAX NUMBER:
EMAIL:
J 1HZ-tV) A IV ~
(Number and Street
-OO~ /
~ l~ANIC ~MulIJd7 ~~
)/21'; e ~--(\A .<1-, ~ ~ )? l)
(State) (Zip Code)
fJ67-OoSl.
I.
LO~ ~ETAIN~D BY: ~
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NAME OF PRINCIPAL/CLIENT:
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. SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
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III. CITY AGENCIES/INDIVIDUALS 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): J A
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
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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":
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
DYes iP~O: Are YOU lobbyina on a oendina aoolication for a Deyelooment Aareement with the City or
aoolication for chanae of zonina mao desianation or chanae to the City's Future Land Use
Mao?
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..
Yes D No:
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 P NG CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXP ES OR COMPENSATION DURING THE
REPORTING PERIOD.
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:
Signature of Principal/Client:
VI.
LOBBYIST IDENRFI~ATION:
[] Produced 1D ~-,v-\-vl2 e... rb~
Form of Identification
PRINCIPAL IDENTI(tll'ION:
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[] Produced ID l C v'-.,. ·
Form of Identification
""~~~.~~'" Mario J. Medina
lJ Personally known (Principal) $~~~:. Commission #D0291987
;';:'. ~i} Expires: Feb 17, 2008
",~1Jo;~~~" Bonded 1bru
'"..,,\\ At1ardio BoDdiDg Co., Inc.
State of Florida, County of Miami-Dade
Sworn and subscribed lef9re me
This 2!i-day of ~V
[J Personally known (Lobbyist)
VII.
SIGNATURE AND STAMP OF NOTARY:
~ FORCLE~
Annual Registration fee: [ ] Yes ] No Amount Paid #
Lobbyist Registration Form receiv and verified bY~
F:\CLER\$ALL\MARIA-M\Lobbyi5t\LOBBYIST fORM 0 .
Date Paid
Revised 12{08{04