Michael A. Pizzi/Choice Waste Services~ f~11A~JiIBEACH
LOBBYIST REGISTRATION FORM ~ I ~'~ ~ ~ ~ .; ~ ' ~ (~ ~ F i ~; k
Lobbyist means all persons employed or retained, whether paid or not, by a prinripal who seeks to encourage the passage, defeat or modification of
any ordinance, resolution, action or decision of any commissioner; any action, derision, recommendation of the City Manager or any city board or
wmmittee; or any action, decision or recommendation of any rity personnel during the time period of the entire derision-making process on such
action, decision or recommendation that for seeably will be hQand or reviewed by the dty co mission, or a city board or committee. The term
spedfically indudes the prinripal as well a an employee eng~ed in lobbying activities. The "Lobbyists" has specific excl alone. Please
refer to Ordinance 2004.3435.
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i c~trnurvt rvt7nnestrc: r-~ rvunntstK: EMAIL:
I. LOBBYISTjIE,TAI E ~ Y/~~~ ~ ~~
'RINCIPAUCLIENT:
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NAME AND ADDRESS
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E NUMBER:
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 3319 ~~~ - 3 A~ I ~ ~ 20
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a corporation, Partnership or Trust [Section 2-482 (c)]
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~~Q~ ~"~ ~ ~~
(Zip Code)
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(Optional)
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST: ~~ ~ ~ L~~ ~ ~°~L /l~~~v~2 ~iZk r?.d4,Qs
u.SP -~ FIC LOB~Y ISSUE:
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Issue
in detail):
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ul. G~ITY-AGENCIES%II+[DI~'ID.UAL:S TO~B'E?`Lll7BtBIED: 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 Z-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 moritFts 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 me 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) ~L ~ C ~ ~00
B) PRINCIPAL'S DISCLOSURE (OF LOBBYI;
(Required).
COMPENSATION): Sa O
w'~'f
The following information must be answered:
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1 } Pursui~t to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Po6curement Issues":
present or pendinct award for woods, equipment or service?
2) Purs~nt to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Rea state Development issues":
application for chance of zonin4 mac desictnation or chance to the Citv'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
corpo on or entity without special compensation or reimbursement for the appearance, whether direct, or
indire t, to express support of or opposition to any item, shall register with the clerk as required by this
sect' n but, shall not be required to pay any registration fees.
reimbursement. .
V. SIGNATURE UNDER OATht:
ON OCTOBER 7sT OF EACH YEAR_,__EACH __LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH LISTING LOBBYING EXPENDITURES AS WELL AS COMPENSATION
RECEIVED IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR R. A STATEMENT SHALL
BE FILED EVENJF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATI N URING THE REPORTING
PERIOD.
Signature of Lobbyist
I do solemnly swear that all of the foregoing facts are and correct and that I have read or am familiar with the
provisions contained in Section 2-482 of the Miam~ a ity Code and all reporting requirements.
Signature of
Signature of
Vl. LOBBYIST IDENTIFICATION:
~c ~~
~7Produced ID ~,~C~%~• 5~i -;~,~'- ~C%~~ `~
Form of Identification
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This_ /~_day of ~z~~~ , 2009
CEO-C~'~_!._ / ~n~ ~~ J C,
Signature of Public Notary -State of Florida
Notarization of l_obbyist's signature
PRINCIPAL IDENTIFICATION:
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Form of Identification
^ Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This~day of - ~~N , 2009
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Signature of Public Notary -State of Florida
Notarization of Principal's signature
TO BE COMPLETED BY CITY
Annua{ Registration fee: ]Yes [ ] No Amount Paid $
Lobbyist Registration Form received and verified by:
STAFF ONLY __
MCR # Date Paid
F:\CLER\$QLL\aFORMS\LOBBYSST FARMS\Lobbyist Registration Form 21I09.doc
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Revised 02/Y1/2009
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PJ,IAf~~IBEACH
City of Miami Beath, 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: / l ~ ~ ~~~-''~-~ ~ ~ G~~1
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.
L ~~
Signature: ate:
F:ICLERILOBBYtSTILobbyist Registration Form 3270B.doc