Jorge E. Dorta-Duque/Charles Gorup Hotels, Inc.m 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, derision or recommendation of any rity 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 inriudes the princpal as well as any employee engaged
in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
NAME OF LOBBYIST: (Last) (First) (M.I)
BUSINESS NAME AND ADDRESS (Number and Street) (Gty) (State) (Zip Code)
TELEPHONE NUMBER: ~ FAX NUMBER EMAIL.
I. LOBBYIST RETAINED BY:
GC
NAME OF
Gt s ~~t~-~- L'~ (~ A-f ~~
(Number and Street) (City)
(State) (Zp Code)
BUSINESS NIiME AND ADDRESS
TELEPHONE UMBER: FAX NUMBER: (Optional) EMAIL: (UpUOnai~
Fili 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:
1Z~r~~,~~~ ~(~~~~ ~C
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
'~ ~ ~ ~ ~% ( ~~ z~~ ~. I j '' Lr .L ~Ci
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR 077'IERt /
A) LOBBYIST DISCLOSURE: (Required) ~~,,.(~LL~ /) ~~~ ~' i.{~~ t`7` ~'7 t ~``-EC-C / F'~~ ~~~~ ~du~~''i
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). ~ ~ i1.i CC `~ (c~ ~ (~c> • Cy dL(.,?-~.) '
~t
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 `~" No• Are you lobbving on a present or pending bid for aoods, eauiument or services, or on a
present or oendino award for aoods eauiument or service
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
Ye No: Are o lobb in on a end'n a li tion for a Dev to ment A ment with th i or
aoolication for chance of zoning map designation or chance to the Citv's Future Land Use
Mao?
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--"ti31 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..
^ Yes No: Are o re resentin a not-for- rofit cur oration or nti w' ou ial m nsation
or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1~ OF EACH YEAR, EACH LOBBYIST
STATEMENT UNDER OATH, LISTING LOBBYING
RECEIVED, IN THE CITY OF MIAMI BEACH FOR TlM
SHALL BE FILED EVEN IF THERE HAVE BEEN NQ~E;
REPORTING PERIOD. 11
I do solemnly swear that ~N"~of
familiar with the provisioF(s cunt
requirements. ,
Signature of Lobbyist:
Signature of Principal/Clie '~
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
foregoing fa true
i in Section 2-482 of the
~ TO THE CITY CLERK A SIGNED
AS WELL AS COMPENSATION
CALENDAR YEAR. A STATEMENT
~R.60MPENSATION DURING THE
of Lobbyist
and correct and that I have read or am
Miami Beach City Code and all reporting
PRINCIPAL IDENTIFICATION:
Form of Identification
Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
^ Produced ID
Form of Identification
~C~Personally known (Principal)
State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
Sworn 19~ ' i\ sQr ~fRl'eyt0~~a ~~ Swp~p, and subscri_ ed before me
ThIS a~i'bf `~~ ay';c~; '
='~ 'P;• Co mission # D = r • = ~~~:)'Comm n xprcesJan 1
'~~,,,, ~ y ' nal otary Assn. ' , miss n 497
. ,~ F ~',,
`~gna ure of Public Notary - ate of Florida '~ Sig {fife of is ~~ 2:'rida
No rization of Lobbyists signature Notarization of Principal ignature
FOR CLERK'S USE ONLY/'
Annual Registration fee: [ ]Yes [ ] No Amount Paid J ~ < ~ MCR # ! ~ ~ Date Paid / ~ ~
Lobbyist Registration Form received and verified by: / ! _
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc Revised 12/08/04
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, `^'N'w.miomibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.573.7254
LOBBYIST NAME: ~~ ~> P-(v ~fi2.. ~';~t
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, o
to immedict~el~
Signatur .
~~__
1~:-;vis~~l o~;oa~2oo~
an issue I have registered to lobby on has been resolved, I am required
tify the City Clerk's Office of lobbyist withdrawal in writing.
Date:
,. ;
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