Aaron B. Perry/Miami Beach Chamber of Commerce1/C~ ~ `~~ e~ r~ ~
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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 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)
1
BUSINESS NAME AND ADDRES (Number and Street) (City) (State) (Zip Code)
TELE HONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINEq BY:
OF
BUSINESS NAME AND ADD ESS (Number and Street] ~ (City) ~ (Staate) (Zip bode)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
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:
u.SPECIFIC LOBBY ISSUE:
Issue to be lobbied
ul. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED.: Pursuant to City Code Section 2-482(8) 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 City
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): ~ ;,~
(Required)._
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 C~NO: Are you lobbving 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
Meal Estate Development Issues":
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.
reimbursement. .
V. SIGNATURE UNDER OATH:
n~i n~Tnoro ~ ST /~\r r w /., , \/~
- -'--- ..~ ~.~.... ~.....-...v..
RECEIVED IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL
PERIOD.
Signature
Produced ID l' L ~~-+6~
Form of Identification
„~~~ 1lSABELSA'iCFIHl
~~'~: -"'~•~ MYCOMt~~ kn n (Lobbyist)
. ~ " ' ~`~ BaMed~T1 ~' ~ 13, 2013
~'~~ ND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Swom to and subscribed b ore me
This ~~ day of , 2009
o C ~
Signature of Public Notary -State of Florida
Notarization of Lobbyist's signature
I do solemnly swear that all of the foregoing facts
provisions contained in Section 2-482~ft~is-Miami
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
ie and correct and that I have read or am familiar with the
City Code and all reporting requirements.
PRINCIPAL IDENTIFICATION:
-17(~'~)~Produced ID _ ~`- ~ ~k G,C~U ~ CjU~'"~~`~7~' ~~~
Form of Identification
^ Personally known (Prin~i]~i~).~0i~` ~~y(AMMISSI099Dt
~~ FJ(PIRES: April 13, 2013
~~` Bonded Thru Notary PubNC Undawrttera
State of Florida, County of Miami-Dade
Sworn an!yd~s~ubscribed efore me
ThisC`=~~'~-~y of , 2009
Ce
e_.-
Signature of Public Notary -State of Florida
Notarization of Principal's signature
TO BE COMPLETED BY CITY C K'S STAFF ONLY
Annual Registration fee: [ Yes [ ] No Amount Pa' $ C Date Paid
.Lobbyist Registration Form received and verified by: \
;4c1„s~l„~~~~otar~s~~rosaYs§ joss}t}~bl~~~:e~i t ~c~ .~rr~ a ~. a~,. Revised 02/11/2009
. ,.
application for change of zoning map designation or change to the Citv's Future Land Use
Map?
~ MIAMiBEACH
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City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, wvrw.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME:
CityClerk@m iamibeachfl.gov
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.
_ O~
Date:
F:ICLERILOBBYIST\Lobbyist Registration Form 32708.doc