Cynthia J. Brown/Miami Beach Gay Pride~t
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City of Miami Beach Office of the City Clerk ~ ~
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1700 Convention Center Drive, Miami Beach, FL 33139
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LOBBYIST REGISTRATION FORM r
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat or rtfc9fficatf
any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the City Manager or any gy boa r
committee; or any action, decision or recommendation of any city personnel during the time period of the entire decision-making process on each
action, decision or recommendation that foreseeably will be heard or reviewed by the city commission, or a city board or committee'Ttrhe `ti~
spec'rfically inGudes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusio~ Plbdt~
refer to Ordinance 2004-3435. /~
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NAME OF LOBBYIST: (Last) (First) (M.I)
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
NAME
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
gut 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 I DIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
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Issue to be lobbied
ul. CITY AGENGIESlINDIVIpUALS T4 BE LOBBIED: (Pursuant to City code section 2-a82(g>
include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise to an
appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code Section 2-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the
commencement of service of City personnel to be lobbied.)
A Full Name of Individual Title B An Financial, Familial or Professional Relationship
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u.SPECIFIC LQBBY ISSUE:
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): ~"`
(Required). ~'r/
The following information must be answered: c7 a
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1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions BycLob~sts
On Procurement Issues": ~ a O
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^ Yes ~,No• Are you lobbvina on a present or aendina bid for aoods. eauiament or services, or on a w
present or aendina award for aoods. equipment or service? U=, y
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyis~On
Real Estate Development Issues": -" N
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^ Yes ~NO' Are you lobbvina on a pending application for a Develoament Agreement with the City or
application for chance of zoning maa 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 ^ No• Are you representing snot-for-profit corporation or entity without special comaensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
A\I AATA~C~ AST AG CAf~l..l VI
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 Qfitt)e Miami Beach City Code and all reporting requirements.
Signature of Lobbyist:
Signature of PrincipaVClient: ~--•'
VI. LOBBYIST IDENTIFICATION:
Produced ID ~~ ~ ~~~~ ~ (~ (D1 ~~76 ~(
Form of Identification
^ Personally known
VII. SIGNATURE AN F?Isi~F RY:
~' 'o^ MyCli(~igy
State of Florida, County of ~~e F,lp'yM~SS~9UC
Sworn to an~subscribed before ~9F boy
This '~ (c da~fa.[, 2 ~Z~~ry'~ni~ O,~Q
/7 ~ n n - r' !/ _ n /~ ~io~ 2p~0 416
Signature of Pul~c Notary -State of 6
Notarization of Lobbyist's signature
PRINCIPAL IDENTIFICATION:
~X Produced ID ~l _~Y C~ //Q b l 7~ 7~°
Form of Identification
^ Personally known (Principal)
State of Florida, County of Miami-Da.
Sworn ar~l subscrib d before me
This ~ r day of ~, 2008
5(gnature of ~'ublic Notary - State~6f"F
Notarization of Principal's signature
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TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: ]Yes [ ] No Amount Pai 3 MCR # Date Pald ,,^
Lobbyist Registration Form received and verHied by:
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City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
CityClerk@miam ibeachfl.gov
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LOBBYIST NAME: ~~ ~ ,~•
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I understand that no later than October 1st of each year, I must file the fc~pwl~
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 imme tely n tify the City Clerk's Office of lobbyist withdrawal in writing.
Signatu
I t d ~ (~
Date:
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