Ronald W. Shane/Miami Beach Watersports Center, Inc.
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MIAMIBEACH
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) (First) (M.!)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: ' EMAIL:
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAl/CLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (aty)
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TELEPHONE NUMBER: FAX NUMBER: (Optional)
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(State) (Zip Code)
EMAIL: (Optional)
Fin out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)l
. NAME OF CHIEF OFFICER, PARlNER, OR BENEFICIARY:
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. IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORA;i;':ARlNERSHIP OR TRUST:
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II. SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDMDUALS 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 HOURLY,
FLA T RA TE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
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B) PRINOPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
NONE
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 0 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
section but, shall not be required to pay any registration fees..
V. SIGNATURE UNDER OATH:
ON OCTOBER 1sT OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, USTlNG 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 NO EXPENDITURES OR COMPENSATION DURING THE
REPORTING PERIOD.
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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 provisions contained in Section 2-482 of the Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist:
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Signature of Principal/Client:
VI.
LOBBYIST IDENTIFICATION:
PRINCIPAL IDENTIFICATION:
U Produced ID
U Produced ID
Form of Identification
V Personally known (Lobbyist)
Form of Identification
~nallY known (Principal) NOTARY PUBDC.STATE OF FLORIDA
~ Elaine Roden
Commission #DD378278
Expires: DEC. 09, 2008
State of Florida, County of MiamHDadded Thru Atlantic Bonding Co., Inc.
Swom and subscribed before me
ms dtJ"day of ~:i2:J)(.,.-
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Signature of Public Notary - State of Florida
Notarization of Principal's signature
VII. SIGNATUREi'MfM"TpWfi@.~T~mUDA
. .~ Plaine Roden
State of Flonda, Coun I-Dace, .
Sworn to and subscrib ~mlSs IOn #DD378278
This (,tJ\. day of ExPl~~ DEC.. 09, 2008
o e ru Atlailft'C Bonding Co., Inc.
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~ignature of Public Notary - State of Florida
Notarization of Lobbyist's signature
FOR CLERK'S USE ONLY
Annual Registration fee: [ ] Yes [ V1 No Amount Paid ~ .-" MCR #
Lobbyist Registration Form received and verified by: / rJ!jJ_ =-
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc.l. -
Date Paid
Revised 12/08/04