American Interstate
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(Oty of Miami Beach, City Code Chapter 2, Division 3, Section 2-481)
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S E P , 0 2002 (
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City of Miami Beach Office of the City Oerk
1700 Convention Center Drive, Miami Beach, FL 33139
Email: dtyderk@ci.miami-beach.f1.us
LOBBYIST REGISTRATION FORM
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DATE QUAUFIED AS LOBBYIST
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I. LOBBYIST RETAINED BY:
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NAME OF PRlNOPAl/CUENT:
19: 30 fV\~~ Av~
BUSINESS ADDRESS: (Number and Street) (City) (State)
t72-S;-~OO
TELEPHONE NUMBER: FAX NUMBER: (Optional)
(Zip Code)
EMAIL: (Optional)
Fill out this section if prindpal is a Corporation, Partnership or Trust [Section 2-482 (e))
.
NAME OF CHIEF OFFICER, PARTNER, OR BENEFI~RY:
L<: 1<0 i S2~cf'o/'l
UST ALL PERSO~S HOLDING, DIRECTlY OR INDIRECTlY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
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SPEaFlC LOBBY ISSUE:
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III. CITY AGENaES/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 HOURL Y,
FLAT RATE OR OTHER):
A) LOBBYlSfDlSO-OSU..{ 1~ ~~ ~ ~~L
B) PRINOPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
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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 S on 2-482 of the Miami Beach City Code as amended, and all
reporting requirements.
Signature of Principal/Client:
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Signature of Lobbyist:
VI. LOBBYIST IDENTIFICATION:
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~ Produced 10 L- \ 2-0 Ll w 59 45 L(
Form of Identification
Q 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 10 -rJ.J day of ~ 2002.
'YI'A "IlY SEAL
LILLIAN BEAUCHAMP
NorARY PUBUC STATE OF FLORIDA
COMMISSION NO, DD109289
MY COMMISSlON EX?.:!.::~. 29.'006
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Signature of Public Notary - State of Florida
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Print, stamp or type name of Notary Public
FOR CLERK'S USE ONLY
Registration: K1 ACCEPTED [] REJECTED
DATE:
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If rejected, state reason:
Registration fee paid: ~Yes [ ] No !l. ::a
[ ] 'fsh ~ Check MCR # 97"\
DATA ENTRY DATE: c::r lj' L .2002 ENTERED B . \j:J
1 I
1 First Revision - 05/17/02