Nina Boniske/Miami City BalletMiAMIBEACH
City of Miami Beach Offic~ of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
Lobbyist means all Parsons 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
pedod of the entire decision-reeling process on such action, decision or recommendation that foreseeebly will be heard or reviewed
by the city commission, or a city board or committee. The term sPacifically includes the principal as well as any employee engageE
/n lobbying activities. The term 'Lebbl/iM~' ham ~ecific exdmianL Pleaae refer te Ordinance 2004-34:~S.'
NAME OF LOBBY],~'I': (Last) (First) J~ (M.I) ,
BUSINESS NAME AND ADDRESS (Number and Street) (City) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: EMAtL:
I. LOBBYIST RETAINED BY:
PRINCIPAL/CLTENT: ~J' -- - I '
~SZNE~ '~E ~D ~D~SS (Number and S~) (C~) (S~te) (~p
q ,,
LEPHONE ~UMBER: F~ NUMBER: (OpfionaO E~L: (O~1)
Fill out thb section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
NAME OF CHEF OFFICER, PARTNER., OR BENEFLC3ARY:
· IDENT[FY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSFEP ~ITEREST ~1 SUCH
CORPORATION, PARTNERSI~P OR TRUST:
ITl, CITY AGENC2ESIINDZVIDUALS TO BE LOBBZED:
iA) Full Name of JndividUal/Title
B) Any Financial, Familial or Professional Relationship
DZSCLOSURE OF TERHS AND AMOUNTS OF LOBBYIST COHPENSATION (DTSCLOSE WHETHER HOURIY~
IV.
FL4 T RA TE OR OTHER,):.
A) LOBBYIST DISCLOSURE: (Required) ~"~0 L -/~P" L"~
. I
B) PR~NC'LPAL'S DISCLOSURE (OF LOBBYIST COMPENSATTON): (Required). q~
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":
D Yes 1~ No: Are you Iobb¥inq on a present or pendinq bid for cmods, ecluipment or services, or on a
· present or pendinq award for qoods, eouipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
BYes ~ No: Are you Iobbyinq on a Dendincl application for a Development Aqreement with the City or
application for chanqe of z0nina map desiqnation or chanae to the City's Future Land Us~
Map?
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 ~ No: Are you ~ '
repr~ntmq a not-for-profit corporation or entity without special compensation
or reimbursement..
v. SIGNATURE UNDER OATH:
ON OCTOBER 1~r OF EACH YEAR, EACH LOBBY[ST SHALL SUBMI'r TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH· LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
RECEI~/ED, IN THE CITY OF MIAM! BEACH FOR THE PRECED!NG CALENDAR YEAR. A STATEMENT
SHALL BE F!LED EVEN !F THERE HAVE BEEN NO EXPENDZTURES OR COMPENSAT[ON DUR/NG THE
REPORT!NG PERIOD. ~
Signature of Lobbyist
! do solemnly swear that all of the foregoing facts are true and correct and that ! have read or am
familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and all reporting
requirements. ~~~...e~~~~
Signature of Lobbyist:
Signature of Principal/Client: d~ E~o
V/. LOBBYIST IDENTZI~CAT/ON:~ PR/NC/PAL IDENT/F/CATTON:
[] Produced ID
Form of Identification
Personally known (Lobbyist)
[] Produced ID
Form of Identification
~/ersonally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade_ '~ * ' State. ~.Florida, County of Miami-Dade
Sworn t~xand subscribe,~ before me _ ~ ~ Sworn~and subscribed before me:,.
T is ~ day/~ ~1~'~.. , ,;~1:)~}~-;~ ;', ~.,~ ~'*~' .... .,.'~his ~d~ of ~~ , 2~
No~'rization of Lobbyi~s.~si~r~a re No~rization of Principal's sighature
~nnual Recitation fee: [~ ] Yes [ ] ~o ~ou~t ~aid lDO ~ ~CR · ~G[~ ~ate ~aid
kobbyist Re~i~mtion ~orm received and verified by: ~