Brakken, Eric J.m ,MIAMIBEACH
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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 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, decision or recommendation of any city personnel during the time period of the entire decision-making process on such
action, decision or recommendation that foreseeabiy 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 Orclinance 2004-3435.
NAME OF LOBBYIST: ~` (Last) (First) (M.I)
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BUS~IN~sS NAME AND ADDRESS (Number and Street) (City) Soil ~aD (State) (Zip Code)
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.30~ ~a'2.~~-~
LOBBYIST RETAINED BY:
Cr`rtC ~~GZ~E,1'~ ~ S~,
OF PRINCIPAUCLIENT:
BUSINESS NAME AND
• 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:
NUMBER: 3~5 6`~Z q~~}'
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(Number and Street)
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(State) (Zip
TELEPHONE NUMBER: 30S^ r ~2~D~~ FAX NUMBER: (Optional) 3~ /_-1~Z ~y~ o ~ EMAIL: (Optionap ~ (a ~1 U3'~ ,
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Fill out this section if principal is a Corporation, Partnership or Trust [Section 282 (c)]
n.S`PECIFIC LOBBY 1
>r act ~F ~"\ ~ aM i ~-e~c.
Issue to be
nl. CITY AGE'fNCIESIINDNIDUALS T,0 Bf LOBBIED: Pursuant to City Code Section 2-482(g) include
a statement of the extent of any business, financial, familial, professional or other relationship, giving rise 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 said Clty
personnels' commencement of service with the City to the present date, stating the general nature of the subject
contractual relation.
A Full Name of Individual Title B) Any Financial, Familial or Professional Relationship
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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): ire('
The following inforrnation 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 lobbying on a present or gendina bid for goods eguipment or services or on a
present or pendma 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":
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 representafive 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.
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Yes No: Are you representing a not-for profit corporation or entity without saecial compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
Signature of Lobbyist: __ _ ... `~~," ~•-_ • _.
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Signature of PrincipatlClient:
VI. LOBBYIST IDENTIFICATION: -_ _____
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tl~' Produced ID ' ~il`~J - ~
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Form of Identi i~~
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^ Personally known (Lobbyist) ~ ~
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VII. SIGNATURE AND STAMP OF N ,,~
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State of Florida, County of Miami-Dade
Sworn to and subscribed b-~f-o~re~m-e
This .2~'~ day of~_~~ ! 2009 zg
Sig , ture of - e of Florida
Notarization of Lobbyist's signature
PRINCIPAL IDENTIFICATION:
lld" Produced ID
Form of Identification ~ R
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^ Personally known (Principal) Q ~ ~ a
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State of Florida, County of Miami-Dade y„~o s
Sworn and subscribed before me 6
This ~.~ "'day of , 2009
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Signatur - to of Florida
Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes [ ] No Amount Paid $ --~ MCR # Date Paid
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form 21109.doc Revised 02/11/2009
I do solemnly swear that all of he,~foregoing facts are true and correct and that I have read or am familiar with the
provisions contained in Se o iami Beach City Code and all reporting requirements.
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeochfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: Cr I ^ ~-- ~ ~~~~/"~
I understand that no later than October i st of each dear, I must File the folbwing
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 hove registered to lobby on has been resolved, I am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
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Signature: ~~-_______.__"~ Date:
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