Elaine M. Roden/Watersports CenterV~~
M AM B EAR H ~ ~~ ~- , ~,;~ ~.~~ ~-
City of Miami Beach Office of the City Clerk 2009 SAP i 7 PM 2:37
1700 Convention Center Drive, Miami Beach, FL 331 ~9 _
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LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed or rotaned, whether pad or rat, by a Principal who seeks to encourage the passage. detest or rnoc6ficatiort of
any ortFnemos, resdumon, adios or dadsion of any oomnussioner; any adios, decision, recorrrrrarid~liorr of the City Manager ar any city board or
Committee: a any action. derision or racorrxnerdation deny dly personnel during the time period of the entiro decsion-making process on such
action. decision or recommendation that toreaeeably wiq be heard or reviewed by the aty oommiasiort, or a city beard or commhtes. The term
speciticaly includes the prindpel as weH as any employee engeped in lobbying adiviUea. 7hs term 'Lobbyists^ has spsctflc axdusions. Plwse
Mer to Ordinance 20W-3436.
NAME OF LOBBYIST: (Last) (First) (M,I)
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
i. LOBBYIST RETAINED BY: ( ` ~
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NAME OF PRINCiPAUCLiENT:
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BUSINESS NAME AND ~jDDRESS (Number and Street) (City) (State) (Zip Code)
Fill out this section H prtrtcipal b a Corporation, Partnership or Trust [Section 2182 (c)j
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~ p~j'`~L~ /~, s('//q~ f j~
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRE JTI~Y, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST: %v /`/Tf _
D °I -
to be lobbied (Describe M
111. : Pursuant to City Code Section 2-482(9) Include
a statement of fhe extent of any busirtsss, financial, familial, professional or other rolatbnship, giving rise to an
appearance of an Improprkty wNh arty City personnel sought to be bbbied -further, pursuarrt to Cily Code section 2-
482(ax4) include a statemsrrt of arty contractual rolafionship (paid or unpaid) from 12 months preceding said CHy
personnels' commencsrnertt of service with the City to the proserrt dabs, stathtg the general nahtro of ttts subject
contractual rotation.
A Full Name of IndhridwN tie B An Fnnancial, FamiNai or Professional Relationsh
«Im V'C. Nonl',~
N. DISCLOSURE OF TERMS AND AMOUNTS OF LOB$YIST COMPENSATION (DISCLOSE WHETHER HOURLY, fLAT
RATE OR OTHER:
A) LOBBYIST DISCLOSURE: (Required) ~ (O ,~ p
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Requiter,). ~/D/ll'
The following Information must be answered:
1) Pursuant to Miami Beach City Code Section 2.488 Entitled `Prohibited Campaign Contributions By Lobbyists
O,~n/Pr~ocurement Issues':
^ Yes L~7 No: Are vqu bbbvino on a preserrt or uendina bid for goods, eauiament or senricea, or on a
present or pending award for troods, equiwnent or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled 'Prohibited Campaign Contributions By Lobbyists On
Real Estate Devebpment Issues":
es No: re ou bb ' on n in a 1 lion r a i M A reemen the C or
~giication for chance of zoninu npln,desistnat(gn or change to the Citv's Future Land Use
M8p?
3) Pursuant to Miami Beach City Code 2=4$4 (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 a not for-profd
corporation or entity without spedal compensation or reirr~ursement for the appearance, whether direct, or
indirect, to express support of or opposition to any ism, shall register with the deck as required by this
section but, shall not be required to pay any registration fees.
Y No: u r+e ntin n or c lion r enti s ial corn tl nor
nsim~ursemerrt. .
SIGNATURE UNDER OATH:
1 do solemnly swear that ail of the foregoing fads are true and correct and that I have read or am familiar with the
provisions contained in Section 2-482 of the Miami Beach City Code and all reporting requirements.
Signature of Lobbyist:
Signature of PrindpaUClient: ~~ ~ , c~/~.6~-~-
VI. ~~~~SYIST IDENTIFICATION; PRINCIPAL IDENTIFICATION:
~~~
~~'+P`~'~ AIM gybed ID ^ Produced ID
g . *~ES'MA~ Form of identification Form of Identification
~ eat'' ~t;:•"::r'~'
+r,,,r~ /~Personaily known (Lobbyist)Personally known (Principal)
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VII. SIGNATURE AND STAMP OF NOTARY: ~arp
State of Florida, County of Miami-Dade
Sworn o and sub fore me
T " day of 2009
Signature of Public Notary - nda
Notarization of Lobt~s 's signature
State of Florida, County of Miami-Dade
Sworn and SubSDTme
is ~_day of ,
~N ~ Is.~
Signature of Public Notary -State of Florida
Notarization of P nc al' signature
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1SS~'I
~~ ~~~~~
Signature of Lobbyist
m MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.7411 , Fmc: 305.673.7254
~ossnsT raaME: ~ - /~0~
I understand that no later than October 1st of each vear,. I must file the following
forms, pursuant to Section 2,4$5 of the Miami Beach City Code, with the City Clerk's
__
__
Office for all active lobbying issues.
1 j 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.
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Signature: Date:
F:ICLER\LOBBYIST\Lobbyist Registration Form 32708.doc