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Chris Middleton/Whole Foods Market Group, Inc.to ~o ~ t_T~N 2°'~D. m' h~~IAMIBEACH 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 Gry 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 20043435. i~l. oaf ~.L. NESS NAME AND ADDRI e lJl V / L~7Dt-~'~drJ ~~~~ ~i (Last) (First) /I/,d/ ~ o - B oX LI-t ~ 2~~- . Mtr~ (Number and Street) (City) (S`tate) y~c`1 Pi~Q/1~ FAX NUMBER: EMAIL: _~ 3~1`r( ~f I. LOBBYIST RETAINED BY: VJ Fir 1rG Fdc~~ nn R~KET bgo~~' . fl~C~ NAME OF PRINCIPAUCLIENT: BUSINESS NAME AND ADDRESS (Number an Street City) (State) l (Zip Code) NUMBER: EMAIL: a or Trust Section 2-482 NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~v~Li CLJ ~ ~tJ~~ IDENTIFY ALL PERSONS kiOLDING, DIRECTLY OR INDIRECTLY, A 5°k OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: u:SPEC[FIC L''OBBY ISSUE;. 1 Q 2 o RLT©tJ ~1J . ~ PI !-FoLE ~oobS -MR[z I~~' $ ~7~EJ - '~-~rJ o ~ ~~1 D ~J Issue to be lobbied (Describe in detail): ill. CITY AGEt~1ClES/INDIVIDUALS T:t7 B~~LO:BBIED: 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 Clty 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 Indrndual Title B) Any Financial, Familial or Professional Relationship = ~oM lM,mo,ts~`~ - bES\~-J ~£J>>:V, {.JOt~~ ~7~SLC~nj ~~L~ ~ ~,oP~g-p N©~tE p4g s~~ IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): VI. ~' ~~ g^= ~~a~ ~W~ ~X~ ~ ~~ A) LOBBYIST DISCLOSURE: (Required) The following information must be answered: B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): ~V~~~~S~~'Gm~ (Required}. 1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists On Procurement Issues": ^ Yes ~NO: Are you lobbvinq 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 ~NO: Are you lobbvinq on a pendina application for a Development Agreement with the Citv or application for change of zoning map designation or change to the City's Future Land Use MapT 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 anot-for-profit corporation or entity without saecial compensation or reimbursement. . V. SIGNATURE UNDER OATH: Signature of Lobbyist: Signature of Principal/Client: LOBBYIST IDENTIFICATION: / PRINCIPAL IDENTIFICATION: ~jR~~eK`s toy ,b~a~a e~,~d~ ,c-C ~oProduced ID ~L•~ M ~J~- )o~/~ "9~2'~ ~duced ID /'V/ Z ~ D7~ J ' ~3" (`~~ / Form of Identification Form of Identification 'r` ` ' y ^ Personally known (Lobbyist) SIGNATURE AND STAMP OF NOTARY: of Florida, County of Miami-Dade i~tQ and subscribed before me 1~~ day of off/ .2009 of Public Notary -State of Florida on of Lobbyist's signature ^ Personally known (Principal) ~y..v~ ~. ~ ~ ~ . . ~~..C ~o c. '. ~~.~ ~M. V `I J State of Florida, County of Miami-Dade S ~ ~ ~" ~ ~ worn aril bscribe of re me Thi ti ~ ~ ° ~ ~ ~ ~ a s , 2009 as f' of /hll/~ , ca • y ~N s ~~ ~ Signa(it4e~f P is Notary -State of Fiori Notarization o Principal's signature O ~~ TO BE COMPLETED BY CITY CLERK'S STAFF ONLY ~..- ~° Annual Registration fee: [ Yes [ j No Amount Paid $ O R # Date Paid Lobbyist Registration Form received and verified by: F;\CLER\$ALL\aFORMS\LOBBYZST FORMS\Lobhyist Registration Form 21109.doc Revised 02/1 /2009 I do solemnly swear that a~of a foregoingAfa~s ~a~ree~and correct and that I have read or am familiar with the provisions contained in Secti 2 of the Mi i ~ a y Code and all reporting requirements. ~ /~~,iA.~"~~,IBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florido 33139, www.miamibeachfl.gov CITY CLERK Office CityClerk@miamibeachfl.gov Tel: 305.673.741 1 ,Fax: 305.673.7254 LOBBYIST NAME: ~1~1z-~S tJltq~bC-~~D1J I understand that no later than October 1st of each gear, 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. Zt Signature:. Date• F:ICLER\LOBBYIST\Lobbyist Registration Form 32708.doc