Alison C. Burgos/Aqua Foundation for Women~..
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
Lobbyist means alt 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. _
NAME OF
(First)
ial3 ry~ i2 A~
(Number and Street) (City)
(M.I)
e ~~ 3330
951-a~~ -~G,G) ALlso~18(IKGos ~ M ~ c. C~,11
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
LOBBYIST RETAINED BY:
2 ~o~IJ DA~t.o~l FoR WOMe,n
NAME OF PRINCIPAUCLIENT: '"
1521 i4 ~~D~ Qoac1 ~ t) ~ ~ 1~~~ ~~ rt'_ 3 3 c3~
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
~ 5- S'16 ~ 2 ~ 8 2 ~o.s- 57 ~ - 2 ~ B 3
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
out this section if principal is a Corporation, Partnership or
• 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:
a o09 ~C~ ~i'a/~7L ~ov~-is,~, ~ ~
Issue to be lobbied (Describe in det~
lll. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to city code section 2-a62(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
Z ~ tZ ~~ Z ~ ~~Q gQ~l
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required).
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 288 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
^ Yes ~ No: Are you lobbving on a present or pending bid for goods eau~pment or services or on a
resent or pendmg 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":
^ Yes ~ No: Are ou lobb in on a endin a lication for a Develo ment A regiment with the Ci or
application for change of zoning mao designation or change 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 2-481 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 reoresenting a not for profit corporation or entity without special compensation or
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/Client:
VI. LOBBYIST IDENTIFICATION:
IiyProduced ID L~ ~ ~ZZ'
Form of I fi ~
^ Personally known
VII. SIGNATURE AND STAMP
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
T ~s __1:)._ dav~c f ) '~ _ , 2008
5"ignature of PubJi~ Notary -State of Florida
Notarization o Lobbyist's sianaturp
~~ ~--
PRINCIPAL IDENTIFICATION:
-b~'~1 ~~~ ^ Produced ID~~.~- '(X73- 68- ~~~ - O
~ Form of Identificatio /\
^ Personally known (Principal) ~~
~~ ~ ~ ;
,o ~t> 'yB c' ~
y,~29~sss/o~GC ~~~~09 ssy~~9
~°<29,o~'G~o~.g1~ State of Florida, County of Miami-Dade oyFs % Gc
~a.~9 os worn and subscribed before me °'d 9 ~~ ~'
°,,;, ~o mA o, p 99 ,
"OP°'c 4~~ s day of %2- , 2008 °6s~~,~s~'iO
~s'" J _ G~r"°'o o~y~
ig ature of Publi Notary State of Flo ida '~;,,,~
Notarization of rincipal's signature "`'~
. ~~
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY ~'l°~~ ~~~
Annual Registration fee: [ ]Yes [ ] No Amount Paid $ ~~ MCR,/~ ~ Date Paid Z ~
Lobbyist Registration Form received and verified by: ~~, ~~_~
F:\CLER\NATL\Formsl~obby ~t F'~g',.;~-;,:,,:,: F^ ~z.rr.. ~'
Revised 03/27/2008
p•-
Signature of Lobbyist
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachFl.gov
CITY CLERK Office CilyClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: _ ~~I_~r~ ~ ,,~~ a1~
I understand that no later than October 1st of each veer, 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.
Signature: Date:
I~~vis2d a~~oa;zoos
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