HomeMy WebLinkAboutAlfred Lariviere
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oty of Miami Beach Office of the Oty Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
Email: cityderk@d.miami-beach.f1.us
LOBBYIST REGISTRATION FORM
(City of Miami Beach, Oty Code Chapter 2, Division 3, Section 2-481)
o Check Box if an Amendment
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NAME OF LOBBYIST: (Last)
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BUSINESS ADDRESS: (Number and Street) I ( Ity) (State) (Zip Code) -
TELEPHONL~~ l{~ 7 JA/VfFAXNtt~Z} 'IV? (3/~
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(First)
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(M.I) DATE QUAUFIED AS LOBBYIST
EMAIL:
I. LOBBYI.ST RffaAIrf BY: I
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NAME OF PRINCIPAL./CUENT:
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BUSINESS ADDR SS:
. ,~~ N~'2 ,,).. t{ f-"f EMAIL: (Optional)
Fill out this section If principal is a Corporation, Partnership or Trust [SectIon 2-482 (c))
. NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
. UST ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. /""' SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
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UI. CITY AGENClES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/TItle
B) Relationship
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOUR! Y,
FLA T RATE OR OTHER):
A) LOBBYIST DISCLOSURE:
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): .0 -
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V. SIGNATURE UNDER OATH:
. .
ONOCrOBER. 1st OFDtH V!AR, 'E~CH LOBBYIst SliALL SUbMIt 10 THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, USTING LOBBYING EXPENDITURES IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR.
I do solemnly 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 of the Miami Beach City Code as amended, and all
reporting requirements.
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SignatClre of ~r1nciPaI/Clieht: ,..;. . .~~
VI. LOBBYIST IDENTIFICATION: ~ '. .,' ,
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Signature of Lobbyist:
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~ Produced 10
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Form of Identification
[J Personally Known
VII. SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade
Sworn tg.,al1P SUbscr~ me
This J . j4A-. day of . 2002.
mp or type name of -Notary P"blicJ)?pu~ Cler i:-
FOR CLERK'S USE ONLY
Registration: [] ACCEPTED [] REJECTED
DATE:'
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If rejected, $tate reasOi1:
Registration fee paid: [ ] Yes [ ] No
[ ] Cash [ ] Check MCR #
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DATA ENTRY DATE:
1
.2002
ENTERED 'BY:
1 First Revision - 05/17/02