David Bernard/VinAmericas, Inc./c N- Gra~nl~
m MIAMI BEACH ~~D ~a ~
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 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 fhe 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
spec~cally includes the principal as well as any employee engaged in lobbying activities. The temp "Lobbyists" has specific exclusions. Please
refer to Ordinance 2004343li. ,
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NAM
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BUSINESS NAME AND ADDRESS (Number and Street) (City)q (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAUCLIENT:
(City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
FIII out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~ A,/~v ?~~~~~
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY/AT5v°k OR M,OORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST: ~~~/~ ~C~ / ,,!~
u.SPFEC;IFIC}~LOBB~ ¢~ISSUE:
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Issue to be lobbied (Describe in detail):
ul. ;CITY.}A;GENCIES%IND_INI_DUALS TO .BE„ L'OB'BIE_D: (Pursuant to city code section 2-as2(g)
Include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise to an
appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to Clty Code Section 2-
482(a)(4) Include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the
commencement of service of Clty personnel to be lobbied.)
A Full Name of Individual Ttitl/e n B An Financial, Familial or Professional Relatlonshl
N~/~
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) N~ _ /~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): ~0 /J~
(Required).
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
2)
Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
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.
reimbursement. .
V. SIGNATURE UNDER OATH:
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I do solemnly swear that all of the foregoing cts re t i
provisions contained in Section -482 of the 'ami ea
2' r
Signature of Lobbyist:
Signature of Principal/Client:
``\~~~~* d01~~~p~~BBYIST IDENTIFICATIO
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~:~c 0 ~m=edlD~I~L~(a53/;L~~j~~U~O
u S ~ N ~ ~ ~ = Form of Identification
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y ~~~~ x ^ p~~~nally known (Lobbyist)
/~~~~~b~~1V11.~~~,*~NATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscrib??~~ before me
This ~~ day of UDY~, 200~~
Signature of Public Notary - State of Florida
Notarization of Lobbyist's signature
rest and that I have read or am familiar with the
and all reporting requirements.
PRINCIPAL IDENTIFICATION:
t"J Produced ID
Form oftdent
^ Personally known (Principal
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State of Florida, County of Miami-Dade ~~""
Sworn and subscribed before me
This _~~day of ~, 200
Sighature of Public Notary -'State of Florida
Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration.fee: [ ;] Yes„[.; ] No Amount Paid'$' MCR#. 3027/ io Date Paid _ ~
Lobbyist Registration Form-received.and.verlfied by: ~~(~i~~iu.L~A
F:\C:LER\LOBBYISTG\Lobbyist.Registration Form 32708.doc ~ R@VIS@d Q3~9~
present or pending award for snoods, equipment or service?
application for chansae of zoninct map desistnation or chance to the Citv's Future Land Use
Map?
m MIAMIBEACH
City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CiyClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: ~A ~ ~~ ~ ~!~-~~
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 i sue I hav registered to lobby on has been resolved, I am required
to immediately notify e City C erk's Office of lobbyist withdrawal in writing.
re:
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ate:
F:\CLERILOBBYIST1Lobbyist Registration Form 32708.doc