Adrian Raymond/VCA Grant Unidad
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
NAME OF LOBBYIST:
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BUSINESS NAME~AND
(Last) (First) (M.I)
4DDRESS (Number and Stre (City (State) (Zip Code)
FAX NU ER: EMAIL: ~Kt
1. LOBBYIST RETAINED BY:
NAME OF PRINCIPAUCLIENT:
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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:
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 lobbyin .The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 20043435. `\
CZ~ A ~_ _ ---- _A`-L -~-io_w~
n.SPECIFIC LOBBY ISSUE:: ~ ~ N
to be lobbied (Describe in detail):
nl. CITY AGENCIES/IhIDIVIDUALS 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 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 Individu
l Title B) An Financia
Familial or Professional Relationship
a '' !! a
5v.
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 Id No: Are you lobbying on a aresent or pending bid for aoods equipment or services or on a
present or pending award for aoods, 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 lobbying on a pending application for a Development Agreement with the City or
application for change of zoning map designation or chance to the City's Future Land Use
Man?
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 special compensation or
reimbursement. .
SIGNATURE UNDER OATH:
ST
PERIOD.
v ~
gna re of Lobbyist
I do solemnly swear that all of a for o' g facts are true and correct and that I have read or am familiar with the
provisions contained in Sectio 2-48 a Miami Beach City Code and all reporting requirements.
~.
Signature of Lobbyist:
Signature of PrincipallClient:
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VI. LOBBYIST IDENTIFICATI `~~,\ti\~\PMR~HATFjF~~~~~PRINCIPAL IDENTIFICATION:
^ Produced ID • ~ .~a`y ie~ol9~ ; ~ Produced ID
Form of Iden~fi~.3ti ~ ~•~ `' `~ ;* = Form of Identification
2 : iiDD 832367 ' o "
Personally known (Lobbyist) ~~y'•.~dryBondedmN~'~: ~~o~ Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOffiC, S1A~ ~~~~~~
rulnu~e-~
State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
Sworn to and ubscribe before me Sworn and subscribe before,me
This day of 2009 This ''i day of 009
Sig tur otary -State of Flori a Signature of Public Notary -State Florida
Notariza ion of Lobbyist's signature Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes [\/J No Amount Paid $~MCR # Date Paid % /
Lobbyist Registration Form received nd verified by:
~:i ~~~`,ti~.~ ~-,~~~Rrn~~~s~~~iu" ~~~'ra~aiLtzt~<~y~r-: ~ae~4st~~~t'•~~r .z:~ w -~3'~.ara~°; Revised 02/11/2009
• ~ F v 4 $ # rte-.., _ ~ "~
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: ~-fG?``Y~
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 immediate) oti the City Clerk's Office of lobbyist withdrawal in writing.
Signatu
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D e:
F:ICLERILOBBYIST1t_obbyist Registration Form 3270$.doc