Loading...
Gavcovich, Jerry/lv?? Co lI l rvs - 1V~ TID~vAL TL~2 City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 LOBBYIST REGISTRATION FORM Lobbyist mears all persons employed or retuned, whether paid or not, by a principal who seeks to encourage the passage, defeat or modification of any ordinance, resolution, action or decision a any commissioner; arty action, decision, recanmendation of the City Manager or any city board or canmittee; or arty action, decision a' recommendation of any city personnel during the time period of the entlre decision-malting process on such action, decision or recommendation that foreseeably will be heard or reviewed by the city commission, or a city board a committee. The term specifically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Phase rehr Oo r~rrsnance 2004.9436. Ga~covit ~H J~~y /~o~( ~}n2P ~~c.7's ~ l NTE/L(arZ t~Esr c~,~J ~~lc . BUSINESS NAME AND ADDRESS {Number and Street} {City} {State} {Zip Code} 2~1s ~3/sc,4y~~ Pawn ~2ya h«sni ~z- 33/37 TELEPHONENUMBER:~S, ~3.r~,a FAXNUMBER:~S S'~j 3'7L` EJ(~IIJGo11fGN ~k~+~k~,c~ Cen I. LOBBYIST RETAINED BY: ___ ~Isu~l' NA-n~N~rc.. G~~. NAME OF PRINCIPAUCLIENT: 72~y ~~t/ArNau~'!ioU~.Erf AND DR SS {Number and reef} {Qy } Gol.[.IA/S AJt:. 17/~4r71 P~F.'3e 1BER FAX NUMBER: {Optional} ~5'•S"32. 2 3 t ~ {State} ~1A7NAtl E ~p,~rUck~'u c~n'~• Gc,,. s section if principal is a Corporation, Partnership or • NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5°k OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: II.SPECIFIC LOBBY ISSUE: __uA~Jtrti~A~TI~~ ArPP~~~h--~lonl ~ ~-{ P n - t l0'1'1 ~~r~~NS ~4~Pf . Issue to be lobbied {Describe i etail}: III. CITY AGENCIES/iNDlVIDUALS TO BE LOBBIED: (Pursuant to city cods Section 2d82(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 arty City personnel sought to bs lobbied; further, pursuant to City Code Ssct(on 2- 482(a}(4) include a statement of any contractual relationship {paid or unpaid) from 12 months preceding the commencement of service of Cily personnel to be lobbied.) A Full Name of Individual Title B) Any Financial, Familial or Professional Relationship 9Z -~ ~d 9- X33 6t~~Z V IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION {DISCLOSE WHETHER HOtlRLY, FLAT RATE OR OTNER): A} LOBBYIST DISCLOSURE: {Required} ~~~ ~~ B} PRINCIPAL'S DISCLOSURE (OF LOBBYISPFL~ISATION}: {Required}. ~~~ The following Information must be answered: 1) Pursuant to Mfami Beach City Code Section 288 Entitled "Prohibited Campaign Contributions By Lobbyists On Procurement Issues": Yes ^ No: Are you lobbying on a present or pending bid for floods, eguipm~t or services, or on a present or pending award for goods, equipment or service4 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": I~'Yes ^ No: Are Vou lobbying on a pending application for a Development Agreement with the City or application for change of zoning map designation or change to the Cit~/s Future Land Use Map? 3) Pursuant to Miami Beach City Code 2-484 (h) Any person (excepi 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 registrallon fees. Yes No: Are you representing snot-for-profit corporation or entitywithout special compensation or reimbursement. . V. SIGNATURE UNDER OATH: ON OCTOBER 1ST OF EACH YI STATEMENT UNDER OATH. LIS7 IN THE CITY OF M1AM1 BEACH F EVEN IF THERE HAVE BEEN NO I do solemnly swear that all o,(tly~ provisions contained in SecNo l ~ facts are true and cor Miami Beach City Code T Signature of Lobbyist: _~_ v Signature of PrtncipallClient: ~ VI. LOBBYIST IDENTIFICATION: ~ ^ Produced ID _ ,~~ Fonn of Identification LY Personally known (Lobbyist) VH. SIGNATURE MID STAMP OF NOTARY: arm' that 1 have read or am familiar with the all porting requirements. PRINCIPAL IDENTIFICATION: Produced ID Fonn of IdeMiflcation lI~ Personally known Principal) State of Fbrida, County of Miami-Dade ?'~ ~ of Fbrtda, County of Mfami-Dade Swom to and subscribed before meNOTARYP'UBL10;8TATEOF m and subscribed before me This d of ' "••• Christian Be -~ ;~ `:- E P mission # DD8 day of , 20 s, x Ices: NLY 07, 2012 Signature d biic Notary- ate o nTynm'~c$aarDlNa gnalure of P c Notary-St a -" da Notarization of Lobbyist's signature Notarization of Principal's signature TO BE COMPLETED BY CI CLERK'S STAFF 0 Annual Registration fee: )Yes [ ] No Amolnt Paid MCR ~ Date Paid Lobbyist Registration Form received and vertfled by. F:\CLER'~L©BBYIST1Lobbyist Registration Form 32708.doL'\ ~ • IteViSect 03/27/2008 g , m _ _~ Y t'g ~ St !"f } 6 .p P' ~ L Lf 6 CiFy of Miami daael~, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miam ibeachfl.gov CITY CLERK Office Tel: 305.673.741 1 ,Fax: 305.673.7254 Ci tyClerkCe~ mia mi beac hfl. gov LOBBYIST NAME: ~~ ~AN ~ /! yy 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. Signd~re: ti ate: F:ICLERIL~BBYIS7'ILobbyist Registration Form 32708.doc