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City of Mia Beach Office of the City Clerk ~ "`~ t ' `~ ~
1700 Convention enter Drive, Miami Beach, FL 331~c~ ~~~ _5 ~~~ II; I 1
LOBBYIST REGISTRATION FORM ~"j~' ~~~~ yy~~ tt~ ((11 ~~ [r'~
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the p~s~Ag~ d~f~~oF4itbdif~aftiotl~ pt ~ (, ~~_
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 lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 20043435.
Pask.a( Kirk..
NAME OF LOBBYIST: (Last) (First) (M.I)
m MIAMIBEACH
yy i rater I(Y1usi c Lon Terence 3450 1~ E 1 a Tern . F~~l.a~d . Fc. 33
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
i V1~er' I"71u~i C_ Cc~n~'etence , .ZnC .
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Bu~l~$s ~~3 -"~~ ~~
TELEPH`fONE NUMBER:
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34~ N~ to ~errc~ce F~•~ 3333
(City) , - , _ _ (State) (Zia Code)
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I,u!-vr~n N~uscL Cows=
EMAIL:
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Fill out this section If principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: LoU { S Pj,~11~
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST: ~i~ ~~ ~ `i I I;Qm ~~~~~
II.SPECIFIC LOBBY ISSUE:
VCPI Touii~t ~ld~
Issue to be lobbied (Describe in detail):
iii. CITY AGENCIES/INDIVIDUALS 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 C1ty 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.
Familial or
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~~
' IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
Quired}. -- c5 Qr~_ e
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 1L1 N0: Are you lobbying on a present or pending bid for goods, eauipment or services. or on a
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":
^ 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 change to the City's Future Land Use
Map?
3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of
"IobbyisY' 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 snot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
PRINCIPAL IDENTIFICATION:
Produced ID ~~r1 ~ ~ 1,.- -
Form of Identification
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
~° Produced ID ~~DY)~ ~~(,~.
Form of Identification
^ Personally known (Principal)
State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
Sworn to and subscribed before me Sworn and subscribed before me
This ~_day of ~ ~DIfUBLIC-STATE OF FLORID his day of , 200g10TARY PUBLIC-STATE OF FLORIDA
Yvonne Katechie ••"""••- Yvonne Katechis
• -:Commission # DD897049 • ~= Commission # DD897049
Signatu i -Stag es: JUNE 08, 201 ignatu blic Notary -State o- rda xpires: JUNE 08, 2013
Notarizatio fLobb fist's i~'axvnrrnvncaormr~cco.,mrcNotarizatio of Principal's signatu~~THRDA~`'r`caovnINCCO.,INC.
TO BE COMPLETED BY
Annual Registration fee: ]Yes [ ] No Amount Paid $
Lobbyist Registration Form received and verified by:
Paid
Revised
I do solemnly swear that all of the foregoing facts are true and cor d that I have read or am familiar with the
provisions contained in Sectionf thg,AA1 j~ni Beach City Co and a reporting requirements.
.-• i
m MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.7411 ,Fax: 305.673.7254
CityClerk@miamibeachfl.gov
LOBBYIST NAME: h 1 ~ ~ PG~S
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 Cler ' Office of lobbyist withdrawal in writing.
SignatGre
/~ ,j~~O
Date:
F:\CLER\LOBBYIST1Lobbyist Registration Form 32708.doc