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(City of Miami Beach, City C;ode Chapter 2, Division 3, SectiO~2-481)
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CITY (I ,."..""S DEP
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Sf? (J () 2002
By_
JimfL
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
Email: dtyclerk@d.miami-beach.f1.u5
LOBBYIST REGISTRATION FORM
NAME OF
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(M.!) DATE QUAUFIED AS LOBBYIST
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BUSINESS ADDRESS: (Number and Street) (aty)
JYC?~? 17
TELEPHONE NUMBER: -
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(State)
JY/J7
FAX NUMBER:
EMAlL:
I. ~~~EDBY:
NAME OF Pru{:(~,~r;L ""'t
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BUSINESS ADDRESS:
TELEPHONE NUMBER:
FAX NUMBER: (Optional)
EMAlL: (Optional)
Fill out this section if prindpal is a Corporation, Partnership or Trust [Section 2-482 (e)l
. 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): ' I.
III. CITY AGENCES/INDMDUALS TO BE LOBBIED:
A) Full Name of Indivldual/TItle
B) Relationship
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'N. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLAT RATE OR OTHER):
A)1<<'k DISCLOSURE: ~cm,
A"-€"<< ~'" -...#t- P".rd) /l;4-/~~--
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B) PRINOPAL'S DISCLOSURE (OF~BBfI COMPENSATION):
1';> 000 - p~ r-yy.,,,-#-..
V. SIGNATURE UNDER OATH:
ON OCTOBER 1 Sf 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 contained in Section 2-482 of the Miami Beach City Code as amended, and all
reporting requirements. ~
Signature ~ _
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Signature of Prindpal/Client: -j{~.. 'If: f/:'~ ~.R
VI. LOBBYIST IDENTIFICATION: 0-
f~L t t:.02LfO-07' -h?-lfb3-o. ~ nJo,3.
~ Produced ID Se1H f. t-, ~(;L
Form of Identificatlon
a Personally Known
VII. SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade
Sworn tOb"d SUbscrIV~e
This day of ~ . 2002.
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I Signature of Public Notary - State of Rorida
,; ,.;~!,:'li;"" SIAO SHEN-HUA
;; ..,\. .[~ ~.\ MY .::OMMISSION , CC 871633
:"'~ .; EXPiRES: September 15, 2003
. , .: "~A. .lon<1<lO Tl1ru Weslem Surely Company
Print, stamp or type name of Notary Public
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Registration: [] CEPTED [] REJEcrED
If rejected, 'state reason: /" .//
Registration fee paid: l.JIfes [ ] No ./
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DATA ENTRY DATE: 2002 ENTEREDBY~
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FOR CLERK'S USE ONLY
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DATE:
1 F1~ Revision - 05/17/02
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