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Rene D. Gueits/Salsa Enterprisesm 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, deasion or recommendation of any dty 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 aty board or committee. The term specifically includes the princpal as well as any employee engaged in lobbying activities. The teen "Lob~rsts" has specific exclusions. Prefer to Ordinance 2004-3435. ^\ / ` / , NAME OF OBBYIST: (Last) (First) (M.I) BUSINESS NAME AND ADD SS (Number and Street) (City) (State) (Zip Code) TELEPHONE NUMBER: FAX NUMBER: EMAIL: I. LOBBYIST RETAINED BY: r NAME OF PRINCIPAL/ IENT: BUSINESS NAME AND A DRESS (Number and Street) (Gty) (State) (Zp Code) gas a~~ ~ i ~~s ~o© ~~~~~~ ~ ~ .c~ 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: II' • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: II. SPECIFIC LOBBY ISSUE: Issue to be lobbied (Describe in detail): IIL CITY AGENCIES/INDMDUALS TO BE LOBBIED: ~ A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship 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). 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": present or pending 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": app cation for change of zoning map designation or change to the City' Future Land Use 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 with the clerk as required by this section but, shall not be required to pay any registration fees.. or reimbursement V. SIGNATURE UNDER OATH: ON OCTOBER,1~ OF EACH YEAR, EACH LOB ST SHALL SUBMIT TO THE CITY CLE A SIGNED STATEMENT UNDER OATH, LISTING L(~B NG EXPENDITURES, AS WELL AS COMP SATION RECEIVED, IN THE CITY OF MIAMI BEACH OR THE PRECEDING CALENDAR YEAR. A STA MENT SHALL BE FILED EVEN IF THERE HAVE BEEN EXPENDITURES OR COMPENSATION DU G THE REPORTING PERIOD. _ igna of Lobbyist I do solemnly s ear that all oft oregoing-facts re true correct d that I have read or am familiar with the rovisions con fined in Section 2- 2 City Code and all reporting requirements. Signature of Lobbyist: Signature of VI. LOBBYIST IDENTIFICATION PRINCIPAL IDENTIFICATION: Produced ID ~. ~~-- ~~f Produced ID `l~ L 4J ~ - Form of Identificati~ Form of Identification ^ Personally known (Lobbyist) v, ^ o ~~N~ VII. SIGNATURE AND STAMP OF NOT ~~ ~o,¢ State of Florida, County of Miami-Dade -~ ~ ~; ~' Swom to and subscrib ,before me ~ c Z is ~_da o U ~"~1 , 20~7~ ~ ~ ~ ~ ~/1,(. ~., ~ ti. ~ g , i , Signature of Public Nota y.,.,," ry -State of Florida a ' Notarization of Lobbyist's signature i~ Annual Registration fee: [ ]Yes [ ] No Amount f Lobbyist Registration Form received and verified by: _ F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM OS.doc ^ Personally known (Principal) °" a . ~ ~ y UJ ~ ,O~ ~ _ x~: ~ -_ State of Florida, County of Miami-Dade -~ ~ ~ - . `~ ~' 9 Swor and subscr.'~ed before me ~ ~:cc ~ ~, This. c~iy ofJtt- Glf} 2 ~ Signature of Pu61ic Notary -State of Florida - Notarization of Principal's signature iiE ONLY a0 ; ~ICt~ # Date Paid ~ ~~ d~ ~' a Revised 12/08/04