Adrian K. Dabkowski/Tom bowman, The Fresh Marketm 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, 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 "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
Dabkowski Adrian K•
NAME OF LOBBYIST: (Last) (First) (M.I)
Kimley-Horn and Associates, Inc. 5200 NW 33rd Avenue, Suite 109 Fort Lauderdale Florida 33309
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(954) 535-5144 (954) 739-2247 Adrian.DabkowskiC~Kimlev-horn.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
Tom Bowman, The Fresh Market
NAME OF PRINCIPAL/CLIENT:
628 Green Valle Road Suite 500 Greensboro NC 27408
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
336.272.1338 336.601.8965 tombowman@thefreshmarket.com
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:
Redevelopment of NW West avenue & 18`h Street -Variance Approvals, and Conditional Use Permit
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
Planning Dept., HPB, BOA, Planning Board, City Commission * None
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* Unless an issue is legislative in nature, HPB, BOA, Planning Board, and City Commission members are not lobbied outside of a public hearing setting.
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER
A) LOBBYIST DISCLOSURE: (Required) $ 132 46 per hour
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":
Yes X No Are you lobbvina on a present or pending bid for goods eauipment or services. or on a
present or pendina award for aoods eauipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
Yes X No Are you lobbvina on a pending application for a Development Agreement with the City or
a~ lication for chance of zoning map designation or chance to the Citv's Future Land Use
Map?
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 X No• Are you representing anot-for-profit corporation or entity without special compensation
or reimbursement. .
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 CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES O COMPENSAT URING THE
REPORTING PERIOD.
Signature of Lobbyist
I do solemnly swear that all of the foregoing
familiar with the provisions contained in Sectic
requirements. ~'~'
are true and correct and that I have read or am
32 of the Miami Beach City Code and all reporting
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
Produced ID
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VII. SI - - NOTARY:
PRINCIPAL IDENTIFICATION:
Produced ID ~~ ~~ Siv I
Form of Idei
Personally known (Principal) ~ ~ ~~
Q°,aPF-poj'~tiijss~ Fq~C
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State of Flori a, County of Miami-Dade
worn s~bscrib b f me
hi day of , 20
Signatur of ublic otary -State of Florida
' Notarization of Lobbyist's signature
State of Florida, County of Miami-Dade °'a2p°~2g ~s3p
Sworn and subscribed before me `a~`~o~°ro Qre
ThisoZ6~day of QV~ ST , 20 0~ ~"'ass
~./,~.~1 UiV~ ~FILLrv~
Signatur o Public Not ry -State of Flo da
Notarization of Principal's signature
FOR CLERK'S USE ONLY ~,
Annual Registration fee: [ ]Yes [ ] No Amount Paid -~_aS~ ,-- MCR ~~~ ate Paid ~~ ~~
Lobbyist Registration Form received and verified by: Entered By: ~ ~ ~ ~'
F:\CLER\$ALL\MARIA-M\LObbyist\LOBBYIST fORM OS.doc ~ Revised 12/08/04
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City of Miami 9each, 1700 Convention Censer Dr'nre, Miami Beoch, Fbrida 33139, v+w+Y.miamibeochfl.gov
CITY CLERK Office Ci1yClerk~miomibeochR.gov
rel: 305.673.7411 ,Fox: 305.673.1254
Lt~BBY1ST NAME: I-1 d. ~ i Q. t' \ ~ `=' k ~y l1. ~ ` ,. ~- i
I understand that no later than tto ._r 1st of veer, 1 must file the following
forms, pursuant to Section 2,485 of the Miomi Seach Ciry Code, with the City Clerk's
Office for all active lobbying issues.
1 J Lobbyist Expenditure Form
2j Disclosure Form
Failure to file these forms on a timely basis will result in my name being transmitted ro the
Miami-Dade County Commission on Ethics and for code violation evaluation.
In addition, once an issue I hove registered to lobby on has been resolved, I am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
-b~-- ,,...,.,.-.,...•_._. Date.
Signature:
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