Joseph Pena/Miami Dade College``~ai~~i
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FbRM
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 derision of any commissioner; any action, derision, recommendation of the City Manager or any rity board or
committee; or any action, derision or recommendation of any rity personnel during the time period of the entire derision-making process on such
action, derision or recommendation that foreseeably will be heard or reviewed by the rity commission, or a rity board or committee. The term
spec'fiically indudes the prinripal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 2004-3435.
Pena Joseph
NAME OF LOBBYIST: (Last) (First) (M.I)
Miami Dade College 300 NE Second Ave. Miami FL 33132
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-237-3959 305-237-109 u
TELEPHONE NUMBER: FAX NUMBER: EMAIL: ~~~~ ~ ®__ 1J ,~
I. LOBBYIST RETAINED BY: ~/~~
Same as Above
NAME OF PRINCIPAUCLIENT:
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
FIII out this section if principal is a Corporat(on, Partnership or Trust [Section 282 (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:
u.SPECIFIC LOBBY ISSUE;
VCA Cultural Tourism Grant
Issue to be lobbied (Describe in detail):
ul. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to city code section 2-as2(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
VCA Grant Board
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
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A) LOBBYIST DISCLOSURE: (Required)
Non profit
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): NOn Profit
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 Flo: Are you lobbvina on a present or pending bid for goods. eauipment or services, or on a
present or pending award for goods, eauipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues°:
^ Yes ~ No: Are you lobbvina on a pending application for a Development Agreement with the City or
application for change of zoning map designation or change to the City'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 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 you representing anot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
Signature of Principal/Client:
VI. LOBBYIST ID~,ENTIFICATION:n
Produced ID5 ~ IIJ~,I~~ ~~{~~~J
~,~y~ orm of Identification
~~~4~D -~p~.o
^ Personally known (Lobbyist)
PRINCIPAL IDENTIFICATION:
~ Produced ID
Form of Identification
^ Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
S~wom to gn~,subycrib d be
T is / da of , 2008
Public Notary -State of F
of Lobbyist's signature
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This day of , 2008
Signature of Public Notary -State of Florida
Notarization of Principal's signature~~ ~ Fv~
----J TO BE COMPLETED BY CITY CLERK'S STAFF ONLY N r ~ ~
Annual Registration fee: [ ]Yes [ ] No Amount Pald S - MCR ~ Date Paid
Lobbyist Registration Form received and verified by:
F;\CLER~l.OaBYLST\i.obbyist Registration Form 32708.dac Revised 03/27/2008
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I do solemnly swear that all of the foregoi acts are true a a that I have read or am familiar with the
provisions contained in Section 2-482 of a Miami Beach C' Code n reporting requirements.
Signature of Lobbyist: '-~~~
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) non profit
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): non profit
(Required). _h '-~
0
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The following information must be answered: -~ °D ;~j
c ~ r~ .
1) .Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributionsr'B_y Lobbyists,..
On Procurement Issues": '~
~; ~ '~
^ Yes ^ No: Are you lobbvina on a present or pendina bid for goods, equipment or services, or Q~ a pcvsent
or pendina award for aoods. equipment or service? ~; ~ ,,~
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lob~ists On
Real Estate Development Issues": '`~ ~
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, shall register with the clerk as required by this
section but, shall not be required to pay any registration fees.
^ Yes ^ No: Are you representina snot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 7sT OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNE
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATIO ~ ~. ~
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALEND YEAR. A STATEMENT SHAL ~ ~
BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES COMPEN ION DURING THE REPORTIN
PERIOD. ~ ~ Q
~ ~~
S t e 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 t ~ ~?
provisions contained in Section 2-48 of t e Mi i Beach City Gode and all reporting requirements. ~' :'
Signature of Lobbyist:
Signature of Principal/Client: ,
'a„„
VI. LOBBYIST IDENTIFICAT N: PRINCIPAL IDENTIFICATION:
^ Produced ID ^ Produced ID
Form of Identification Form of Identification
Personally known (Lobbyist) C~Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
Sworn to and subscrib d before me Sworn and subscribed before me
This ~,~_day of ~ , 20 O~ This day of , 200 yJ
--~
Signatur ublic Notary -State of Florida natur ub is Notary -State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY ~-/~
Annual Registration fee: [ ]Yes [ ] No Amount Paid $ ~~~ ~ " `
MCR # Date Pa'
Lobbyist Registration Form received and verified by: Z
i
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, vrww.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,fax: 305.673.7254
~~ /
LOBBYIST NAME: ~/6.r !mil ~ ~/`J~
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.
7~ / ~ O
Signature: Date:
F.ICLERILOBBYiSTILobbyist Registration Farm 32708,doc