Keith Donner - Globetec Construction, LLC
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City of Miami Beach Office of the City Clerk ZQIO JUL 12 PIS I: 03
1700 Convention Center Drive, Miami Beach, FL 3~~A ~~~i,~',,S ~~ ~,~~
LOBBYIST REGISTRATION FORM
Lobbyist means alt persons employed or retained, whether paid or not, by a principal who seeks to en~urage the passage, defeat or modification of
eny ordinance, resolution, action or decision of any commissioner; any actron, decision, recommendation of the City Manager or any ary 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
acton, deasion or recommendation that foreseeaby will be heard or reviewed Dy the caty commission, or a city board or committee. The term
specifically inWudes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specHic exclusions. Please
refer to Ordinance 2004-3436. ~^- ) ~ f
d /!/t ~/ !~ t fJ-~
AE OF LOBBYIST: (Last) (Firsq
1. L08BYIST RETAINED BY:
(M.I)
~ ~ ~ y~
(state) (Zip Code)
~..~„ .
G~~ES--EC Cc~S`~`RVCn SO l~~ ~ LLC
NAME OF PRINCIPAUCLIENT: '
G~o6f~c ~~s~rR~c~~ . ~~' - ~/~~-~! N • P~~~~~" ~ ~ ~~~ gE,gcN ~ 33~`~-3
B SINESS NAAAE AND ADDRESS (Number and Street) (City) (State) ~ (Zip Code)
S~-5~_-_305 ~i'hti-~,Qn _ 33a~
out this
a
or Trust [Section 2-482
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
q~r~a>~aa ~ssc~~-
• ,IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST: o(,+A 51`EC , .SlYL .
II.SPECIFIC LOBBY ISSUE:
ITB # 17-09/ 10, ROW Infrastructure Improvements, Neighborhood No. 1 Z- S. Pointe Phases III/IV/V
Issue to be lobbied (Describe in detail):
iii. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Fursuartt to city code section 2.482(8)
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 De lobbied; fuRher, pursuant to City Code Section 2-
482da)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the
commencement of service of City personnel to be lobbied.)
City Manager & administrative staff
Mayor and City Commission
or
/J 2. rJa~ 4I ~.f ..../I .t ,7 .
• ~ RATE OR OTHER): .
A) LOBBYIST DISCLOSURE: (Required) ~ '
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): W 15 OOO ll~l ratC' retallleT'
(Required). `~' ~
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2488 Entitled °Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
I/ I Ye~ No: Are you lobbvinq on a uresent or pending bid for goods, equipment 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":
IYe~ ~No: Are you lobbvinq on a ~nding aapiication for a Development Agreemen with the Citv or
a°aiication for chanoe of zoning map designation or change to the City's Future Land Use
MBD~
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-profd
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.
I-IY~s~/INo: Are you representing anot-for-profit corporation or entity without special compensation or
reimbursement. .
Y. SIGNATURE UNDER OATH:
Signature of Lobbyist:
Signature of PrinapaUClient:
VI. LOBBYIST I
PRINCrtP"AL IDENTIFICATION:
B~ Produced ID (~'(f~~;i~.e~ ~ ~ Produced ID
Form of Identification
Form of Identification
^ Personally known (Lobbyist) i~'Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
Swom to and subscrib d b fore me Swam and subscri ed ore ine~
his ~_day 20p8-~(~ This _~day o , 20D8,/6
' ture of Public Notary - State o n na u o ublic Notary - State o ri a
Notarization of Lobbyist's si~pature Notarization of Principal's signature
TO f3E COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ~,j Yes [ j No Amount Paid a ~ - MC # Date Paid
Lobbyist Registration Form received and verFFed by:
F:\CLER\HATI\Forms;LObby~ ~rtEg:e..-r.-,;;,sF...~,.n~.; Revised0 /27/
i do solemnly swear that all of the foregoing fads are true and correct and that 1 have read or am familiar with the
provisions contained in Sedionl s-4$2 of the Miami Beach City Code and ali reporting requirements.
.-
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miomibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.7411 ,Fox: 305.673.7254
LOBBYIST NAME: f~ (~ i ~~ /~/ a nn. ~
I understand that no later than October 1st of th vegr, I must file the .Following
forms, pursuant to Section 2-485 of the Miami Beach City Code, with the City Clerk's
Office for all active lobbying issues.
1) lobbyist Expenditure Form
2) Disclosure Form
Failure to file these forms on a timely basis will result in my name being transmitted to the
Miami-Dade County Commission on Ethics and for code violation evaluation.
In addition, once on issue I have registered. to lobby on has been resolved, I am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
'-~ - ~ ~L ~f~ _
Signot re:. Date:
Ravisacl Q2/041200$
.... ..