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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 w rrrodifrcafion of
any ordinanaj, resolution, action or deasion of any commissioner; any action, deasion, recommendation of the City Manager or any a1y board or
committee; or any action, decision or recommendation of any city personnel during the time period of the entire deasion-making proa~ss on such
aGion, decision or recommendation that foreseeably will be heard or reviewed by the aty commission, or a aly board or COTRllttee. Tare term
speafia311y includes the prindpal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. fuse
refer to OMinance 2004-3435.
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State)
(Zip
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I. LOBBYIST RETAIN Y:
N OF PRINCIPAUCLIENT:
BUSINESS NAME AND ADD (Number and Street) (City) (State) (tip Code)
EMAIL:
Fill out this section if principal is a Corporation, Partnership or Trust (Section 2x482 (c)] ~~ ~,
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• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: _
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• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTERES'
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SUCH CORPORATION, PARTNERSHIP OR TRUST: _
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u.SPECIFIC LOBBY ISSUE: ~~ r;:~ ~--~~
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Issue to be lobbied (Describe in detail):
ul. CITY AGENCIESIINDIVIDUALS TO BE LOBBIEp: (Pursuant to city code section 2-4s2(g-
include a statement of the extent of any business, financial, familial, professional or other relationshlp, giving relse 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 relationshlp (paid or unpaid) from 12 months precedlnp the
commencement of service of City personnel to be lobbied.)
A Full Name of Individual Title B) An Financ
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l, Familial or Professional Relationshl
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE w!'tl£THER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) ~~ ....
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST CO ENSATION):
(Required). ~ '-'
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contritx~stions By Lobbyists
On Procurement Issues":
" 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":
application for change of zoning map designation or change to the Citv's Futare Land Use
Mao?
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 snot-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 cleric as required by this
_ section but, shall not be required to pay any registration fees.
reimbursement. .
V. SIGNATURE UNDER OATH:
...~ ....~.."~., .sT .... ........,~
/ (/-Signatu of Lobbyist
I do solemnly swear that all of e f egoing facts are true and corn ct and that I ad or am familiar with the
provisions contained in Secti 2 2 the Miami B it Code and a rting requirements-
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
^ Produced ID
Form of Identification
LJ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP
State of Florida, County of Miami-Dade
Sworn to and subscribee, before me
This ~n~ ~ day of ~i20C
Signature of Public Notary -State of Florida
Notarization of Lobbyist's signature
0 Produced ID
PRISGLLA FRIEDLAND
MY COMMISSION # DD 543864
EXPIRES: August 23, 2010
Bonded Thru Nota~I(~U~a~r~i
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This ~ d~
Form of Identification
own (Principal)
JS'jX'P~," PRISCIIlA FRIEDLAND
~' MY COMMISSION # DD 543864
'~` EXPIRES: August 23 2010
~~?r~~t~§'s- eon~d Thru Notary Public Undeiwdters
County of Miami-
scrib d before me p.
iv of 20~
Signature of Public Notary -State o4 F
Notarization of Principal's signature
TO BE COMPLETED BY CI CLERK'S STAFF ONLY
Annual Registration fee: ]Yes [ ] No Amount Pai MCR ;K ate Paid
Lobbyist Registration Form received and verified by:
F:\CLER\L£}BBYI5T\LObttyis# Reyistrat:ion Form 32708.c1 Revf®ed 03/27/2008
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City of Miami Beoch, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachH.gov
CITY CLERK Office
Tel: 305.673.7411 ,fax: 305.673.7254
CityClerk@miamibeachH.gov
LOBBYIST NAME: ~~
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 imm/~tely notify the City Clerk's Office of lobbyist withdrawal in writing.
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F:1Cl.ER1LOB13Y15T1Labbyist Registration Forrn 32708.dpc