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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
Email: cityclerk@ci.miami-beach.fl.us
LOBBYIST REGISTRATION FORM
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(City of Miami Beach, City Code Chapter 2, Division 3, Sed:!on 2-481)
'0 Check Box if an Amendment
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NAME OF LOBBYIST: (Last)
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BUSINESS ADDRESS: (Number and Street)
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TELEPHONE NUMBER:
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(First) .
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(City) r (State) (Zip Code)
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(M.I) DATE QUALIFIED 1>5 LOBBYIST
FAX NUMBER:
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EMAIL:
LOBBYIST RETAIN~ BY:
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NAME OF PRINCIPAL/CLIENT:
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BUSINESS ADDRESS: (Number and street) (City) (State)
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TELEPHONE NUMBER:
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(Zip Code)
FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill out this section If princlpalls a Corporation, Partnership or Trust [Section 2-482 (e)l
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NAME OF CHIEF OFFICER, PARTNER~BENEFlCIARY: rv
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LIST ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
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II. SPEaFlC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOUR! Y,
FLA T RATE OR OTHER)
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A) LOBBYIST DISCLOSURE:
B) PRINaPAL'S DISCLOSURE (OF LOBBYIST ,SOMPENSATlON): 10 (7 IV 'f tf I- rr ftJ..R 7Y?-11V t::"c{
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V.. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO 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 containe in Section 2-48 f the Miami Be . as amended, and all
reporting requirements.
Signature of Lobbyist:
Signature of Principal
VI. LOBBYIST IDENTIFICATION:
~ Produced ID
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Form of Identification
Cl Personally Known
VII. SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This II~ day of alA........... ,2002.
Signature of Public Notary - State of FI~rida
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Print, stamp or type name of Notet, Pl:Il9lie
FOR CLERK'S USE ONLY
Registration: [jI ACCEPTED [] REJECTED DATE: 1e=J (- ~
If rejected, state reason:
Registration fee paid: D<I Yes [ ] No
[)CI Cash [ ] Check MCR #
DATA ENTRY DATE: ,II { , 2002 ENTERED BY:
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I First Revision - OSf17f02