Alison C. Burgos/Aqua Foundation for Women
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City of Miami Beach Office of the City Ci rk ?i7p9®~C - ~ P~ •
1700 Convention Center Drive; Miami`Beach,
LOBBYIST REGISTRATION FORM ~ 3~,~~, i, ~' ~ ~l j ~; C)/-_ 4
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Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encou ge the passage, defeat or modification of
any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation df the City Manager or any city board or
committee; or any action, decision or recommendation of any city personnel during the time period of th lentire 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 tens
specifically includes the principal as well as any employee engaged in lobbying activities. The term "Lob gists" has specific exclusions. Please
refer to Ordinance 2004.3435.
NAME OF LOBBYIST: (Last) (First) (M.I)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) ( State) (Zip Code)
95y -ae - L/s ~t/F,3uRGo~'o5 d/j ~G• <D/n
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RET
A
INEb BY:
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NAME OF PRIN AUCLIENT:
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BUSINESS NAME A~VD ADDRE (Number and Street)-
3 r- S'16-'Z-7S4 (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) ~ EMAIL: (Optional)
gut 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°h OR
SUCH CORPORATION, PARTNERSHIP OR TRUST:
OWNERSHIP INTEREST IN
,,..
II.SPECIFIC LOBBY ISSUE:
/a _~~~ ~' r r 1 2~ l o ~'es><~ tu- ~ ~6 ~l,~e, ~ ~vor~
Issue to be lobbied (Describe in detail):
_~ ... _.
nl. C.ITY 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 oth r 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) fro 12 months preceding said City
personnels' commencement of service with the City to the present date, stating tkhi general nature of the subject
contractual relation.
A
F
ull Name of Individual Title B An Financial,
Familial o Professional Relationshi
,
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v ~ ~ ou moo/ /~em ~ r /
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,, IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) ~ / /
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required). ~,~ 6 ce)>?; pE
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited
On Procurement Issues":
u Yes ~!. No: Are you lopbving on a present or pending bid for goods, eat
present or pending award for goods. equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign
Real Estate Development Issues":
E WHETHER HOURLY, FLAT
. -c.-.
Contributions By Lobbyists
By Lobbyists On
Map?
3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except tho a 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 fort e~ appearance, whether direct, or
indirect, to express support of or opposition to any item, shall register ith 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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Signature of Lobbyist
1 do solemnly swear that all of the foregoing facts are true and correct and that I ave read or am familiar with the
provisions contained in Section 2-482 of the Miami Beach City Code and all reportin requirements.
Signature of Lobbyist: ~ if-
Signatur of Principal/Client: ~ •
VI. LO ST IDENTIFICATION: PRINCIP NTI ICATION:
'`' edlD~~~a-oo3-~g 9a6 0 6aa-oo -6~-~~~ -v
*`~-J Form of Identification ~ ~~ ~ o ~ of Identification
c~ ~
~ ~~ rsonally known (Lobbyist) Q'~~ known (Principal)
VI SIGNATURE AND STAMP OF NOTARY: ~ ~~'~
~' of Florida, County of Miami-Dade of Florida, Cou ty of Miami-Dade
•':.,q,~ ' orn to ~~ subscribed before me ;, - rn an subscrib before me
is / day of 1 ,`_2009 1'n ~ is day of 00~ ~
~-~ ~ ~ C '_~~L.
Signa e f Public Notary -State of Florida Signature of Public otary -State of Florida
Notarization of Lobbyist's signature Notarization of Prin f al's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
,Annual<Registratiori`fee: '' Yesa[. ] No .~Amount`P,aid' MC ~# . ' zDate'Patd
,Lobbyis4 RegistrationrForm received:and verified:by:: 2 I
f:\CLER\$ALL\aFORMS\LOBBYIST.FORMS\LobbyistRegistration Form-21109:doc ~ ~ `Revised 02/11/2009
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.m
CITY CLERK Office CityClerk@
Tel: 305.673.7411 ,Fax: 305.673.7254 r
LOBBYIST NAME: /-~/~SrJH C'
tr~~s
.gov
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 C de, 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 ir1 my n'am being transmitted to the
Miami-Dade County Commission on Ethics and for code violatio evaluation.
In addition, once an issue I have registered to lobby on has be n resolved, I am required
to immediately notify the City Clerk's Office of lobbyist withdra al m writing.
Signature:
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D te:
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F:ICLER\LOBBYIST1Lobbyist Registration Form 32708.doc