Glenn D. Harris/Fox Pan American Sports
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MIAMI BEACH
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
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BUSINESS NAME AND ADDRESS (Number and reet)
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TELEPHONE NUMBER:
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 " bbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
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NAME OF PRlNCIPAL/CUENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (C" )
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TELEPHONE NUMBER: FAX NUMBER: (Optional)
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AIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)l
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IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
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SPECIFIC LOBBY ISSUE:
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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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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RA TE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) p/t1Zr ov
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST C~ENSATION): (Required).
The following information must be answered:
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Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobl5yists
1)
On Procurement Issues":
~s D No: Are you 10bbvinG on a oresent or oendinG bid for GOods. eGuioment or services. or on a
- oresent or oendinG award for Goods. eauioment or service?
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..
DYes rfo: Are ~ou re~res:n~inG a not-for-orofit corooration or entity without soecial comoensation
or r~bu!J!em~nj;. .
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 PRECEDING CALENDAzrYEA A STATEMENT
SHAlL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COM PENS ON OURlNG THE
REPORTING PERIOD. U~ ~' _~
Signature of Lobbyist
I do solemnly swear that all of the foregoing facts a true and c
familiar with the provisions contained in Section ~82 of the Mia
requirements. ~ ./
Signature of Lobbyist: ~/ ,?-.L.;
Signature of Principal/Client:
D Produced ID
, Form of Identification
/ Personally known (Lobbyist)
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ect and that I have read or am
Beach City Code and all reporting
VI.
Form of Identification
'personallY known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
FOR CLE!d}USE ONLY , , C::l 1 J
Annual Registration fee: [ Yes [ ] No Amount Paid ") ~ MCR # ~t \+.2 Date Paid U 21 60
Lobbyist Registration Form received and verified bY:~, ~B
F:\CLER\$ALL\MARlA-M\Lobbyist\LOBBYIST fORM 0 . ..-:> Revised 12/08/04