Elaine Roden/Miami Beach Watersports Center, Inc.m MIAMBEACH
City of Miami Beach OfFce 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 tiie dty commission, or a city board or committee The term specifically indudes the principal as well as any empbyee engaged
in lobbying activities. The term "Lobbyists" has specific eXNusions. Please refer to Ordinance 2004-3435.
/J ~
NAME OF LOBBYIST:
(I-ast)
BUSINESS NAME AND
I• LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
BUSINESS
ADDRESS
FAX NUMBER:
and
(O~Y)
(State)
EMAIL:
(State) (Zp Code)
TELEPHONE NUMBER:
FAX NUMBER:
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
~Po~~~ cJ~ ~-~}~~'~
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5°h OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
Issue to be lobbied Gibe in detail): ~r
III. CITY AGENCIES/INDIVIDUALS. TO BE LOBBIED:
A) Full Name of Individual/Title I
B) AnyFinancial, Familial or professional Relationship
n/, DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHERr ~
A) LOBBYIST DISCLOSURE: (Required) ,\'n
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). 'V
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":
Yes o: A~e n lorbb ^ in n w resf r oo endin 1 bind n r rods 1 Dui m nt or ervices r n a
2) ~ Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues": -
Y s N Ar ou I bb in on endin a uca r ~~~ ° " ' ~ ~~ fe to the CItV's Future Land Use
~.,.,hcatlon for chance of zonin4 m ~ ~ ~ ~ ~~
Man?
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 anot-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 w'~th the clerk as required by this
section but, shall not be required to pay any registration fees..
~r rPimbur~ment. .
y, SIGNATURE UNDER OATH:
ON OCTOBER 1~ R OATH YLIS'fIN6 LOBBYING EXPENDITURES, AS TWELL ASCCOMPENSATION
STATEMENT UNDE ~
RECEIVED, IN THEN IF THERE HAVEABEEN NOTEXPENDrI'URES OR COMPENSATION DURING THE
SHALL BE FILED
REPORTING PERIOD. ~~, ~ a
~C~ ~ ~
Signature of Lobbyist
I do solemnly swear that al~ f~the~foreSei~ion ~ 82 oft the Miam~rBeach City Codehand allareporting
familiar with the provisions
requirements. rl - /
7/ia.. ti.,/. _
Signature of Lobbyist:
Signature of Principal/Client:
PRINCIPAL IDENTIFICATION:
yI, LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
obb~~~~i CHEEK
~' Personally ~W- i« DD 466605
* ~ 5
~I, SIGNAT s
'~afad~ST~.
State of Florida, County of Miami-Dade
Sworn to and subscribed) before me
This ~_day of f{U~.- - 20~
`~ ..~-
Signature of Public Notary -State of Florida
Notarization of Lobbyist's signature
^ Produced ID
Form of Identification
y 'µY P''~ lav colr>Mlssarl DDO466605
~ersonall known (Prin
. * * EXPIRES: Ocbber 5, 2009
`0>.r~~~~` Bad~dTMuBudpotNot~tYSNVius
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This day of /~. 20Q-7
Signature of lic Notary -State of Florida
Notarization of Principal's signature
,, FOR CLERK'S USE ONLY _ x ,._ Date Paid ~ ~ ~
MCR # ~-
Y~ No Amount id ' -
Annual Registration fee: ~" ~- l [ ] Revised 12/08/04
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\i"I~-M\lobbyist\LOBBYIST fORM 05.d