Michael T. Andrews/South Beach Chamber Ensemble, Inc., ~ City 'of Miami Beach Office of the City Clerk
: ~ 1700 Convention Center Drive, Miami Beach, FL 33139 -
• ~ LOBBYIST REGISTRATION FORM
' LobbyisCmeans all persons employed orretained, 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; dr any action„ decision'or recommendation of any city personnel during the time period of the ehtiFe decisidn-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"
' - §pecifically includes'the principal as well as eny employee engaged in lobbying activities. The term "Lobbyists" has°spedfic exclusions. Please
• - refer to Ordinance;2l104-3 5. ~ '
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- NAME OF"-LOBBYIST: (Las First) (M,)) - -
• _ BUSINESS N MEAN ADDRESS (Number and Street) (City)., (State) (Zip Code)
~a5 .x:7'.3-z! ~ N~~' ~ ~ yv,a-n~~ws 1"j w,~ha~sor;-~'.~a~j.:
` TELEPHONE NUMBER: FAX NUMBER: EMAIL: ~-
- i. LOBBYIST RETAWED 13Y:
.. Se ~'N'1 mat g ~~ C-~~~wib ~c • ~:
- NAME OF PRINCIPAUCLIENT:
~BUSINESS NA E AND ADDRESS (Number.and Street) (City) (State) (Zip Code)
TELEPHON6NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
uh CITY~A`GEN.C~IE`S/IND:I\/IDUAL`S T.O BE>LOB.B:IED: Pursuant to pity Code. section z-4sz(g) include
' ~ .- ' a statement -of the extent of any busir-ess, 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 City 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.
• A :Full Name of Individual Title .. -: B) Any Financial, Familial orProfession~al Relationship
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IV. DISCLOSURE OF•TERMS. AND AMOUNTS OF LOBBYIST COMPENSATION (pISCLOSE WHETHER HOURLY; FLAT
~ro~n . RATE OR OTNER): - . ,
A) LOBBYIST DISCLOSUF~: (Required) - .
. B) .PRINCIPAL'S DISCLOSl1fiE (OF LOBBYIST COMPENSATION):
,_: ...(Required). .,
The. following information. must be answered: - `
1) Pur"scant to Miami Beach City Code Sectioh 2-488-Entitled "Prohibited Campaign Contributions By Lobbyists
~~ On Procurement Issues":
- ^ Yes ®' No: Are you lobbying on a present or pending bid for goods equipment or services or on a
present or pendmg award for goods equipment or services
,, _ •
- . 2) Pursuant to Miami Beach CityCode.2-490 Entitled "Prohibited Campaign,ContributidnsBy Lobbyists On `
Real Estate Development Issues": - ,
' ^ Yes- ~ No: Are you lobbying on a pending application for a Development Agreement with the City or
~_ • apphcatlon for change of zonrng map designation or change to the City's Future Land Use
Map?
3} • Pursuaht to, Miami Beach City. Code 2-484 (h) Any person (except ,hose exempt from the definition of
"lobbyist" as sef forth in Section 2-481 above) who only appears as a representative of ,not-for-profit
. corporation or ehtity without special compensation or reimbursement for the appearance,: whether direct, or
indirect, to express support of or- opposition to any item, shall register witfi fhe clerk as required by ,his
. ~ ~. section but; shall not: be required to .pay any registratioh fees. '~ . -
- ~ Yes ^ No: Are you representing ,not-for-profit corporation or entity without special compensation or
reimbursement. .
- V.. ;SIGNATURE UNDER OATH: ' ` . - )
' - - ~
, - Signature of Lobbyist
'I do solemhly 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 2-482 o th ia`mi Be City Code and all reporting requirements.
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' Signature of Lobbyist: 1~'/~ ,, •' '
W .• . Signature of Principal/Client: yIV -~l~t~/
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
~. y • ,~
, L"f Produced ID ~L-~!~j~ SoS ~ I ~.O . t'l Produced ID {~L# ~ ~ ~~~5~, C76 ~~~
- _~ Form of Identifica ~#~'' ~ ~ Form of Identification
• ~ ^ `Personally known (Lobbyist). ~~~s~,~"~ ,`k
~~„ k` ^ Personally known (Principal) ~ ~ `.,
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• VII:.- SIGNATURE AND STAMP OF NOTA `l~ ~~. - ~
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" State `of Florida, County of Miami-Dade.
;. Sworn-to~and subscribed before me 9 ~ ~ ~
~. ~„ ~, State. of .Florida, Cdunty of Miami-Dade
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`~ _ This 1 day of \, - ~
, 29Br-'Z-(~l ~ 2~ ~, worn ahd subscribed before me •
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. ,, Notarization of Lobbyist's signature. arization of Principal's signature ~ o °.
°1'O BE COMPLETED BY CITY ERK'S STAFF ON Y
' Anriual~Registration fee ~;;[
Yes;[ ] No =Amount P
aid;$
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.Lobbyist Registration Form receivetl and verified'fi
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Date~R9'
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Fi.\CLER\BALI:\aFORMS\LOBBYIST.FORMS\Lobbyist'Registratton Form211Q9.iioc eViSed-02'/11' _2009
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City of Miami Beach,. 1700 Convention Center Drive, Miami Beach, Florida 331'39, www:miamibeachfl.gov •
.. ,
CITY CCERK.Office " . ~ CityClerk@miamibeachfl.gov
. ~ ~ ~ Tel 305:67,3.741 1 ,Fax: 305.673.7254 -~
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LOBBYIST NAME: ~~a~'1 ~'~-~~~ew s
I understand '.that no dater than .October l st 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 aal 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 1 .have registered to lobby on has :been resolved, I am required
;to irrmmediately notify the City Glerk's Office of lobbyist withdrawal in writing..
1~ f l ~ ~~
- . Signature:: .,.Date:
F:\GLERILOBBYIST\Lobbyist i2e,gistration Form 32708.doc