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Dwayne L. Dickersonm p;11;~,:/~IBEACH City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 LOBBYIST REGISTRATION FORM Lobbyist means atl persons empbyed 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 LOBBYIST: (Last) (First) (M.I) Rt~lt~n! f`-~le.~:t.-t~S~Y ~~0 E RROVJIAR'1~ ~I~VP 1~Tt(-Ftrx~ ~-T. LAC~D~©,~ BUSINESS NAME AND ADDR S (Number and Street) (City) (Sta e) ~~~~ D ~ C¢ I 4 Sy Sal ~Y~n 9S~ 3~a ~D~l~ D w-~rs~.t~;cl~~R v~ ~ Rual~.coM TELEPHONE NUMBER: FAX NUMBER: EMAIL: LOBBYIST RETAINED BY: ~3R,1/Tr P~1-La S NAME OF PRINCIPAUCLIENT: yl Q.u~at t G-Rrx~ Si Tc~+~y6 ~er~[~ SOH t~N ~tsC~F~~ID L~f~l S b ff H' ADDRESS (Number and Street (City) (State) (Zip Code) Gr~Q4 ~n~ ~~Z ~~D~ lhr~~il- M TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional or Trust [Section • 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.SPECIFtC LOBBY tSSUE: ~i2~~NCiA/-}~, rs R~~u~T'il~lG 3 t/~~,9-r~lc~ ~i2A~7 >L~cTION _j1/~ -/Ltb ~~ ACt~4~ t~t~ie- ~4 R~ uc ~ sum ~ si D ~ ~~4R(~S, ;~i1/7~/L/d R 5 i ~~ ul. CITY .AGENCIES/INIDtVIDUALS TCJ BE LOBBIED: (Pursuant to city code Section 2-asz(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) Any Financial, Familial or Professional Relationship ~ NONE ~_' ^~ = ~; ~ ~r~iv f ~ ,; p Q. s F N t~ b I = cn o`°)`a .~ -~", U' _~-- c~ ~ `~ ~; ~ _,.; w '-~ =T-; ~ t/ ~~ IV. DISCiASURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOt1Rt-Y. FLAT RATEOR OTNEW: A} LOBBYIST 1~SCl.OSURE: {f>kquired} +,~(l~~ Cam ~~~ 57..1 r7~ B) PRINCIPAL'S Dtt>CLOSURE {OF LOBEy1ST COMPENSATION): (Required) I~DL~.~ ~~( (' M P~tySA-Tiole --- The toitowing information must be answered: 1) Pursuant to Miami Beach City Code Section 2-488 F~itled °Prohibited Campaign Contnbutions By Lobbyists On Procurement Issues": ^, Yes ~ No- Are you lobbvfng on a present ~ pending bid fot woods eau -_ _ or services. or on a present or pending award for goods. eautpmm~t or sgry,} 2) Pursuant to Miami Beach GtS- Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Rest Esta#s Deveiognent Issues": ^ Yes ~ No• Are vg~bbbvirw on a pending aooticaUon for a t)evetopmern ~{igg~)t with the City or application tot t:hantle of zoNna map designation or change to the City's f=uture Wnd t7ee ~? 3) Pursuant to f4liami Beach City Cade 2-484 (h} Any person (except those exempt from fhe deHnitlon of "[obbyisY as set forth k+ Section 2-481 above) who only appears as a reprosentative of a rwt-for-profit corporation of eNity without speaai cmnpensation or reanbursement for tlZe appearance, whether direct, or indirect, to express support of or opposition to any item, shall register witli the clerk as required by this sectron but, shah not be required to pay any registration teas. ^ Yes ~ No• Ara you representintl a not-to root comoration or entity without stlecial compensatig~ ~41{;=~tISl~ SIGNATURE UNDER OATH: ~: #~ ~:~~ ~.~' a . iri, ~~ o ~ ~~ - ~ . ~.,~ 3ignaturc of Princapai/Client .~°' VI. LOBBYIST IDF~1TIFtCASZON:"°^''"°'°~ PRINCIPAL IDENTIFICATION: ^ Produtxtd ID ~ Producx3ti lD Form of identif~aticn Persona8y known (LobbyyLat) VII. SIGNATURE AND STAMP OF NOTARY: State of Florida, Counfy of N6and-Dade Swam to and subsc+i before me Thi day of 2008 atune of Public Notary -State of Florida Notarization of Lobbyist's siQDatUre Form of Identification Personalty known (PTineipal} State of Florida, County of Miami-Dade ar a~ Swom and subscribed before me raga •...8~% PATRICIA BRAVO This ~ da of g ,.: ° , , 2046 # * i~Y COAtkIISSION t DD W2896 -"+ ~'~ ?j .,.~, EXPIRES: October 2,201 i v ' R .~ ~" "s a 1 ~j~'~FOF F~OQ`~~P BOIItIBd ThN BUd9lt ICY S8fYk68 Signature of Pbhlic~or = b`tate of Florida Notarization of in 's signature Annual Registratiot-. tee:.j ] Yes`(....~J No:. Amount Fail S ~` MCR a Oahe Paid Lobbyist Reyisvation Forrn~n3oelved and. verified by:. F:\CLER1liATL\Forms\lnb6vtst Reaisbatron Ponn.doc _ RIVkBd 0 /27~ I do ademnly svrear that aN of the foregoing facts are true and correct and that I have read or am familiar with the provisions contained in Section 2-482 the la I Beach Gty Code and all reporting requirements. Signature of Lobbyist ~iWl+1 ~• ,~~"6"~`m'°""~,. t l ~ . R _ t City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office Tel: 305.673.741 1 ,Fax: 305.673.7254 CityClerk@miamibeachfl.gov LOBBYIST NAME: ~k1Ryd~ L - ~ ~c~F~~~ 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. /2 30 0~ Signature: Date: F:1Ct_ERl1_OBBYISTl1_obbyist Registration Form 3270S.doc 4t (_'~ ~.-r ~~~ ~,~ ~~ Cn• L: ~ r'7 CAE ~~ +.sr r'J •~_ r,~ u? ,--i rJ '~' ___ r__ ~ ~~. ~~ r..a ~ ~~.. ~~ ,w ti!~ I _'~ ..-t 1 ~•! -,-s _,~ ;~;i ~r r~ [.::: ?~ z 7 ..1 z_ d' N O Z ri V W mg cg ~LL ~O ~~ ~v 0 m a c a o.