Dwayne Dickerson/Walgreen Co.w~ Py,,,,<.~ ea
~ MIAMIBEACt1
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 prinripal who seeks to encourage the passage, defeat or modiflcaUon of
any ordinance, resolution, action or derision of any commissioner, any action, derision, recommendation of the City Manager or any dty board or
committee; or any adion, derision or recommendation of any dly personnel during the Ume period of the entire derision-making process on such
action, derision or recommendation that foreseeably will be heard or reviewed by the dly commission, or a dty board or committee. The term
speriflcally indudes the prindpal as well as any employee engaged in lobbying adivifles. The term "Lobbyists" has speclflc exclusions. Please
refer to Ordinance 2004-3435.
i c. I~sor~ p w ~~ nr ~ L
NAME OF LOBBYIST: (Last) (First) (M.I)
RuO~t I~le11DS~.Y „200 E.~Qowr4laD t3Lvn.. srft ~Lt)Ot1?. FT. LAuDP~~ Di4L~ rL 33301
BUSINESS NAME AND ADDRESS (Number and Street) (C ) (State) ( p CZ~-
3155~ 5~7 ~~SO ~~Y ~3~ uoSO .~IJ~4yuE. ~rGKa` SnNlB_ Ru.nwv. coM
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
LOBBYIST RETAINED BY:
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NAME OF PRINCIPAUCLIENT:
Y'T?`N: ~, .~ A__L-~OSYr~-l. !d'l W%L.~r~nT./~i,S.f~/yyy_ DLF~eFi~ . LL /,d7/S
BUSINESS NAME AND ADDRESS (Number and Stretit) (City)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
~SyT 3~v'J SIBS/
FIII out this section if principal is a Corporetlon, 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:
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A Full Name of Individual Title B An Financial, Familial or Professional Relatlonshl
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Include a statemerNCIES/INDIVIDUALS 'TO BE LOBBIED: (Pursuant to Clty code section 2-4s2(g)
e extent of any business, flnanclal, familial, professional or other relatlonshlp, giving raise to an
appearance of an Impropriety, with any Clty personnel sought to be lobbied; further, pursuant to Clty Code Section 2-
482(a)(4) include a statement of any contractual relatlonshlp (paid or unpaid) from 12 months preceding the
commencement of service of Clty personnel to be lobbied.)
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHERJ: 9~
A) LOBBYIST DISCLOSURE: (Required) Y7 ~ I/ ~ ® p
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): ~ ~; Qd ~
(Required). D uR,L~ Cnrn-P ~~V S A Ti o N ~' l
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2.488 Entitled "Prohibited Campaign Contributions By Lobbyists
O~,n(Procurement Issues":
^ Yes t~l No: Are you lobbvina on a aresent or uendina bid for ooods, equipment or services, or on a
present or pending award for ooods. 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 lobbvina on a pending application for a Development Agreement with the City or
application for chance of zoning map designation or chanoe to the Citv's Future Land Use
Maps
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 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. .
V. SIGNATURE UNDER OATH:
Signature of Lobbyist:
Signature of PrincipaUClient: .~F' 1'
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sw to and subscribed before me
T da~•stf~ a~_, 200
Signature of Public Notary Mate of Florida
Notarization of Lobbyist's sionature
PRINCIPAL IDENTIFICATION:
~ Produced ID
Form of Identification
Personally known (Principal)
State of Florida, County of Miami-Dade
Swom d s rib before me
This ~~~~~~;~,-~, 200
Si~hature of Public Notary -State of Florida
Notarization of Principal's signature
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TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ Yes [ j No Amount Paki $ MCR # Date. Paid
Lobbyist Regtstration Form received.and verified by:
F:~CLER\LOBBYtST\Lob6yist Registration Form 32T08.doc ' Revises! 03/27/2008
9
I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am familiar with the
provisions contained in Section 2-4>~2 of~ie Mimi Beach City Code and all reporting requirements.
City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, vrww.miamibeachfl.gov
CITY CLERK OfFice
Tel: 305.673.7411 ,Fax: 305.673.7254
C ilyClerk@m iam i beachN. gov
LOBBYIST NAME: ~ lxJ A Yal ~ L ~ ~ict«solY
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, 1 am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
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Signature Da e:
F:ICLERILOBBYISTtLobbyist Registration Form 32708.doc