Wendy E. Kallergis/MB Chamber of Commers Visitors Centerc i
City of Miami Beach Office of the City CI~Ifi ("' ~ I ~ ~ ~
1700 Convention Center Drive, Miami Beach, FL"33139
LOBBYIST REGISTRATION FORM 2~~~ SEA '~ PM 4= 3d
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to enS~~Q~ d~~e~ ~rfsgOdification of
any ordinance, resolution, action or decision of any commissioner; any action, decision, recommend~timr) aF t~~g o ~y[~y 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
anion, 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 "Lobbyisffi" has specific exclusions. Please
rster to Ordinance 2004-3435.
NAME OF LOBBY (Last) (First) (M.I)
~~~ .
Cam- BUSINESS NAMIlE AND ADDRESS ,,ll (Number and Street) (City)
TELEPHONE NUMBER: FAX NUMBER:
1. LOBBYIST RETAINE,~/JBY~
E„ 11.1'r'il'-'Li V~>~(/t~1.1 i.~~tLli-~vl~~ (~I'-'t~'~/~•
NAME OF PRINCIPAUCLIENT:
gt~1StNESAE AN[~,DDRESS e_
and Street) (City)
=S-3~ ~133(p
~X NUMBER: (Optional)
M ~ ~ isrt~.
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(Zip Code)
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C'~
(Zip Code)
gut this section if principal is a CorROration, Partnership or Trust [Section 2-482 (cjj ~,
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• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
'?v;..,
:-::;~.
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
II.SPECIFIC LOBBY ISSUE:
VC,~- ~ its ~ p~ ~-~~~-r.
Issue to be lobbied (Describe in detail):
Ill. CITY AGENCIESIINDIVIDUALS TO BE LOBBIED: (Pursuant to City Code section 2-482(8)
include a statement of the extent of any business, financial, famitial, 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(aj(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 ship
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B) Any Financial, Familial or Professional Relatio
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RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) ~ LL ~ ~~ ~ ~, ~,ne ~ y~, _ ~~~
B) PRINCIPAL'S DISCLOSURE rOF LOBB T COMP NSATION): , hw'nl~ -y'~L
(Required). LL ~ -'VI (~ (-~~ ~ '~' 1 RQ.. ~~_
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 L'7 No• Are you lobbvino on a aresent or aendina bid for Goods eauiament or services or on a
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":
r-, ^.
application for change of zoning map designation 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
"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, shalt register with the clerk as required by this
section but, shall not be required to pay any registration fees.
reimbursement. .
V. SIGNATURE UNDER OATH:
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:
Signature of Principal/C
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
Personal) knbwn (Cobb ist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This _~_day of $,_2008
Signature of Public Notar~5 -State of Florid
~N~pf Lobbyist's signature
~Con~rionDD~3A1alb T_ 0 BE COMPLETED BY
AIt1~r~E: [ ]Yes [ j No Amount Paid'
Lobbyist Registration Form received and verified by:
F:\CLER\HATL\Form ;~obby >r F~-y.~;,,>-.-,.,~ Fr.:~-!+.~?rr.
PRINCIPAL IDENTIFICATION:
~ Produced ID
Form of Identification
~"':~'.`k~, taEBM>i.8CF1WART2
~rcowslssloNtDOe13~
^ Personally known (Pri EXPMRES:SIipMnlbw8,2012
df as Bonded 1tNU BidpN Nary SMrlce~
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This 1,~day of S~P7~• , 2008
Signature of Public I~(otar~"- State of Fla
Notarization of Principal's signature
STAFF ONLY
Paid
Revised 03/27/2005
~' ~~
Signature of L bbyist
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www,miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fox: 305.673.7254
LOBBYIST NAME:
CityClerk@miamibeachfl.gov
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 J 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:
fi . a, ~-oD~
Date:
i~~wised o2,oa;~oos