Elaine M. Roden/MB Watersports Center
City of Miami Beach Office of the City Clerk
1744 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
Lobbyist rr ail persons employed or retained, whether paid or not. by a principal who seeks to encourage the passage. defeat a modification of
arq ordinance, resdution, action or derision of any commissioner, arty action. derision, recmranendation of the City Manager or any rity board or
cornntittee; or any action. derision or recommendation of any rity personnel during ~e time period of the errtire decision-making process on such
action, decision Ot teoorrlmendetion that foraseeabiy will be heard ar reviewed by the Cdy commission, or a atY board or committee. The term
specifically includes the prirrdpal as well as any employee engaged in bbbying activities. The berm "Lobbyists" has apaettic exclusions. Please
refer bo l)rdlnanea 2004.3435.
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NAME OF L086YIST: (Last) (First) (M.I)
M ~A1Yl i B~f+CN t~1~~TEJ~SJ°~TS G~ ~ t!oS17D /N~i~l-nl C,P~tK J7/e 33,E
BUSINESS NAME,ApND ADDRESS (Number and Street) (Cfty) (State) (Zip Code)
30J~~~o~ t~387(0 c~~~~o/$~/
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LOBBYIST RETAINED BY:
IU I A'!'Y) I , ~~~Cf1 /r~/~nsPo~r275 ~-'~~' /~
NAME OF PRINCIPAUCLIENT:
~S7Io J~JDi~FN' ~~ Di2 . M;An~~~ B~f!-Gfl _ ~L ~~ ~4/
(State) (Zip Code)
Fill out this section if principal is a Corporation, Partnership or Trust [Sectlon 2.182 (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: fL~ /~
u.SPECiFIC LOBBY ISSUE: ~~' ~ ~~~~ ~~~N /~~~+~n-sr~'~.-r S ~i~}-~"-7e,
Issue to be lobbied (Descxibe in detail):
ill. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to city code section 2-4s219)
Include a statement of the extent of any business, flnanctal, familial, profeasfonal or other relationship, giving raise to an
appearance of an hnpropriety, with any CFty personnel sought to be lobbied; further, pursuant to City Code Section 2-
482(8x4) irrclude a statement of any contractual relationship (paW or unpaid) from 12 months preceding the
commencenwrrt of service of City personnel to be lobbied.)
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) ~ I~ ~~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): A /~~~
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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":
aresent or aending award for Goods, eauirJment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
R^eJal Estate Development Issues°:
^ Yes LW No: Are you lobbvino on a pendins~ apalication for a Deveioament Agreement with the City or
aoulication for chance of zpnina mao desiunation or change to the Citv's Future Land Use
Ma°?
3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of
"IobbyisY' 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 cleric as required by this
section but, shalt not be required to pay any registration fees.
reimbursement. .
SIGNATURE UNDER OATH:
I do solemnly swear that all of the foregoing fads are true and correct and that I have read or am familiar with the
provisions contained in Sedior~-482 of the IU~mi Beach City Code and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client: CN "~ ~5
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
Personally known (Lobbyist) r
VII. SIGNATURE AND STAMP OF NO,'~ i
State of Florida, County of Miami-Dade ~~i#~nd~!
Swom to and subscribed before me
This ~2~ „day of cl ~ , • 2008
-~ ., n /~ .
St9nafure of Public Notary -State of Florida
Notarization of Lobbyist's signature
PRINCIPAL IDENTIFICATION:
~ Produced ID
Form of Identification
~Ily known (Principal)*
k1Y C01NfigSlOii # DD'il1d806 ?
2006 'r~taa
EXPIRES: r s
~a ee of Florida, County of Miami-Dade
Sworn and subscribed before me
This,., ~//~day of 2008
c ~~lY L.~ ~ we . w.e'l
~gnature of Public Rotary -State of Florida
Notarization of Princioal's signature
~ 1SSlONt0Ep~46b~
eatditd'M'rI~~S,~~
TO BE COMPLETED BY CITY CL RK'S STAFF ONLY
Annual Registration fee: ]Yes [ ] No Amount P MCR # Data Pald
Lobbykt Registration Form received and verified by:
f:\CLER\LOF,RYIST~Lobbyist Registration dorm 32708.doc Revised 03/27/2008
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Signature of Lobbynst
m
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: ~i L~l /~ ~ ~~ ~ C~ V
I understand that no later than October 1st of each year, I must file the following
forms, pursuant to Section 2-485 of the Miami Beach City Code, with the City Clerk's
Office for all active lobbying issues.
1 ~ Lobbyist Expenditure Form
2) Disclosure Form
Failure to file these forms on a timely basis will result in my name being transmitted to the
Miami-Dade County Commission on Ethics and for code violation evaluation.
In addition, once an issue I have registered to lobby on has been resolved, I am required
to immediately notify the City Clerk's OfFice of lobbyist withdrawal in writing.
,~ ~ ~ .
Signature: Date.
F:ICLEROLt?Bi3Yl~T~Lotabyist Registration Faun 32a'08.doc