George W. Kousoulas-- '' Ins ~ '~ ~~'w
y^` ~ .r
City of Miami Beach Office of the City Clerk ?~II9 APB? 23 P~ ' 2
1700 Convention Center Drive, Miami Beach, FL 33139 ;.1,; , ~2.
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LOBBYIST REGISTRATION FORM "' `~ UI ~ ji ;
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 ti tmye period of the entire decision-making processThe term
action, decision or recommendation that foreseeably will be heard or reviewed b the ci commission, or a cit board or committee.
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.
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Last (First) (M.I)
nlAnnl= (~F I OBBYIST ( )
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BUSINESS NAME AND
30 5 352>
TELEPHONE NUMBER
I. LOBBYIST RETAINED BY:
I~l I g N l ~L 3313 I
(State) (Zip Code)
L,
p~~4S ~' ~-ocamctro~~COwI
EMAIL:
NAME OF PRINCIr,vL~~Llt=i~ ~
yE2C~ ~i~cac.,~ ~o_~ ~?~-E~o~Me~r !~C _~___2_o___LtNCa.~o_~_o~D ---~f!~_~±~ ~~cH_~?----
-------- State (Zip Code)
BUSINESS NAME AND ADDRESS (Number and Street) (City) ( )
FAX NUMBER: (Optional) EMAIL: (Optional)
TELEPHONE NUMBER:
Fill out this section if principal is a Corporation. Partnership or Trust [Section 2-482 (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.
II.SPECIFIC LOBBY ISSUE:
LIIJCD(,It~ EAST ~Aa'KtA1G~ciLl7Y
Issue to be lobbied (Describe in detail):
lll. CITY AGENCIES/INDIVIDUALS TO BE 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 t2 months preceding said City
personnels' commencement of service with the City to the present date, stating the general nature of the subject
contractual relation.
i 41 Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship I
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(Number and Street) (City)
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
---- -------
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--------------------
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATI N)
Re uired ~t..)~1.----~_~L9U11Y~---------------------------------
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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 ~ No• Are you lobbying on a present or pending bid for goods equipment or services, or on a
present or pending 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 Are you lobbying 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 a not for profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1sT OF EACH YEAR EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
_ -___...... ~.,..~...-.~T~~"rn w~ ~w~ci ~ nc !`nnIIDGAICATI(1N
PERIOD.
I do solemnly swear that all of foregoing facts are~e and correct and that I~have read or am familiar with the
provisions contained in Se ~on 2- 2 of Miami B City Code and all reporting requirements.
Signature of Lobbyis . __ -
Signature of PrincipallClient: ___ _ _______________ ___-------------------------
a VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
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0 0 ~ I~ ProducedlD ______________________ ~ ProducedlD _____________________ =
~ Form of Identification ~ "'-, •~`
~ ~ E ~ Form of Identification ~ .,, ~,,••
~ ~ °' a x
Z N ~ z Personally known (Lobbyist) personally known (Principal) T ~ O
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v a LL VII. SIGNATURE AND STAMP OF NOTARY: ~ ~
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x
~ w State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
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"~- ~ Sworn t and subscribed befor me Sworn nd subscribed bef re me
'.m his _~ _ day of ~rl ~__. 2009 s __day of --T"~__ 2009 S ~ p
Sig e of ublic Notary -State of Florida Sign re f Public Notary -State of Florida N
Notari tion of Lobbyist's signature Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
_ ~ . L`Z~ _MCR # _~ _Date Paid ~
Annual Registration fee: [ Yes [ ] No Amount Paid $_1 _ _ -~--
Lobbyist Registration Fo m received and verified bv~ ~ ~`~(Z.~j~l ~~~{?~~(! (r