John Shubin/Mt. Sinai Medical Centerm 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 prncpal 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, deasion 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 speafically includes the principal as well as any employee engaged
in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
SNy ~s ~~ J ~ N t~ Ic
NAME OF LOBBYIST: (Last) (First) (M.I)
S N u t; l >,1 zr- t3 ~' SS ~ to „~1' • c.(. 6 S W ~ ~h S•'t r~, e-f- . 1`l l ~- r' ~- 3 3 ~ 3 v
BUSINESS NAME AND ADDRESS (Number and Street) (City) State) (Zip Code)
(' 3pS, 3~1- 606 C 305 381••~~-s ~ ~ sh~b~ ti. e7 Sh~b ~~.loass.co--+~
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
~''IOV~u'T SINa~~ ("tEp~cR~. CG-NTE~2
NAME OF PRINCIPAL/CLIENT:
`-~ 300 F1 L-ro >J R oqt~ rt, ~- 13E~~1~+, Fc.. x.31 ~}o
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zp Code)
C3o5~ 6?y- 252n
TELEPHONE NUMBER: 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:
~S51irS rela~4e~- ~ ~tC.w.: ~fa~a ~---ai•Ih.4-~ ~roQi<'`~`~
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
C 1"I`~ O f° T'1 ~ ~! h l ,E q 1`t I S t/ V C N G
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHERf
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). t"1'0_, V ~ T `r ~ V U U
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 'I~No• Are you lobbvina on a present or pending bid f r goods equipment or services, or on a
present or Dendina award for goods equipment or service
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
^Yes 111;No• Are you lobbvina on a pending application for a Development Agreement with the Citv or
~,~
application for change of zoning map designation or change to the Citv's Future Land Use
M. au?
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 snot-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 IY.No• Are you representing snot-for-profit corporation or entity without special compensation
or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1~ 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 CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE
REPORTING PERIOD.
~~~ ~ ~-
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: ~~ ~1 ~\~. ~•- ~~
`~~~~~`~~EZN L~K"~'~ii//i
~~~~1y; ~\SSIOIy c~A'~ ~~
i0 J,~13,?Op9 9N:: ~
• ~ • .~
ic! ~•~ S
~ S #DD 435646 _ :~
of Principal/Client:
LOBBYIST IDENTIFICATION:
ID
Form of Identification
known (Lobbyist)
PRINCIPAL IDENTIFICATION:
^ Produced ID
Form of Identification
~ ~....rr.........~..~..+.~...~.~.....
personally known (Principal) ,.~i~""•~ti~s, PpISCILLA FRIEDLAND
:.. ,,t MY COMMISSION # DD 543864
~~. ~~ EXPIRES: August 23, 2010
~~;~ i;b•' bonded Thu Nogry PuWa UndenHitero
State of Florida, County of Miami-Dade
Sworn and subscribed be ore me
This ~',_~-day of i~~~~~"~
/U~1~
Signature of Public Notary -State of Florida
Notarization of Principal's signature
State of Florida, County of Miami-Dade
Sworn to aid subscri before me
This 5~-t day of r S.v 20 ~ ~'
Signature qF Public Notary -,gt~te of Florida
Notari ion of Lobbyist' signature
FOR CLERK'S USE ONLY 9
Annual Registration f~ ]Yes [ ] No Amount Pai MCR # -Date Paid
Lobbyist Registration Form received and verified by: A
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc ~' Revised 12/08/04
SIGNATURE AND STAMP OF NOTARY: