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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.f1.us
LOBBYIST REGISTRAnON FORM
(City of Miami Beach, City Code Chapter 2, Division 3, Section 2-481)
.I!S Check Box if an Amendment
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TELEPHONE NUMBER:
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(First) (M.!) DATE QUAUFIED AS LOBBYIST
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(City) (State) (Zip Code)
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FAX NUMBER: EMAIL:
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NAME OF LOBBYIST: (Last)
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BUSINESS ADDRESS: (Number and Street)
I. LOBBYIST RETAINED BY:
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100 Co~--tL>
BUSINESS ADDRESS:
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(Number and Street)
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(City) (State)
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(Zip Code)
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TELEPHONE NUMBER:
FAX NUMBER: (Optional)
EMAIL: (Optional) .
Fill out this section if prindpalls a Corporation, Partnership or Tl1Ist [Section 2-482 (e)l
? ~~~H:.OF~-r;: 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):
01. cnv AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name Of Indlvidual/llt1e
B) Relationship
,
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: ~ & ~ a ("Y1.P'Yl~ ~ ~
<focol~{ .
B) PRINOPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
*'
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING 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. ./l "7
Signature of Lobbyist: ~ V
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
..s Produced ID
Form of Identification
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VII. SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade 4
Sworn ~q t~d SUbSCri~ ~Xe m,e n., _ . . _ /J _ _ fl--v7 (). A
This ----=t.1-b-day of ',', 2002. G~ ~ ' ~
Signature of Public Notary - State of Florida
~"~':t.~fU",,, Crisele Torres
f:r~. ~:s MY COMMISSION', CC778123 EXPIRES
~~ .~i January 9, 2003
'q,Y:l,' IlONOEDTHRUTROVfAlNINSURANCf,INC Print, stamp or type name of Notary Public
FOR CLERK'S USE ONLY
Registration: N ACCEPTED [] REJECTED
DATE:
ro-~-Cl)..
If rejected, state reason:
Registration fee paid: ~ Yes [ ] No 'LeLl j("
[ ] Cash ~Check MCR # '7 rl~ ~'v
DATA ENlRY DATE: . 2002 ENTERED BY:
1
1 First Revision - 05/17/02
. .
IV. Dl$CLOSURE 01= TERMS AND AMOUNTS OF LOIIBYI$T COMPENSAnON (DISCLOSE WHETHER HOURL Y,
FLAT RArE OR OTHER):
A) LOBBYIST DISCLOSURE; ~~~ ~ (l f"Y'V'Yl~ ~ ~
<fcco\hr .
B) PRINCIPAlOS DISCl.OSURE (01= l.OeavISt COMPENSATION); ~ ~ eft .~ t, ( J
...
V. S1GNATUItE UNMR OATH:
ON oc:tOIER 1ST OF EACH YEAI4 EACH LOBBYIST SHALL SUBM" TO tHE CITY CLERK A SIGNED
STATEMENT UNDER OATH, USTING LOBBYING EXPEHDnURI:S IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR.
1 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 aty Code as amended, and all
reporting requirements.
Signature of lobbyist:
~ Produced 1D _
Signature of Prlndpal/Client:
Vl. LOIJ8Y1St JOENTlFICA:
6/ e~IIY ~0
vn. SIGNATURE AND Sf AMP OF NOTARY OR DEPUTY a.ERIC:
State of Florida, County of Miami-Dade Jc
Sworn ~ 'l'Jd subsalbed. ~tre m.e n
This _=Uh_-,lay of D' , 2002. '-..:.-- ~f..e ~
Signature of Public Notary - state of FlorIda
~~ Crisele'rottea
W; :-& MY COMMISSION' (:C771123 EXPIRES
~ ::lonllary 11, 2003
. .- ~D~THllu'RoYFAlNI~ INC. Print, stamp or type name of Notary Public
FOR CLERK'S USE GNL Y
Registration: ~ ACCEPTeD [] REJECTED
If rejected, state reason:
Registration fee paid: 'f:;:::JYes [ ] No
Ie ~ fsh ~eck MCR #I
PATA eNTRY DATI;: ~ ()~ .2002
DATE:
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State of FJorida, County of Miami -Dade
Sworn to and subscribed 'before me
this l~ day of ~. 2002.
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...~V PlI. OFAClAlNOTARVSEAI.
0'" ~~ DIANA THORSON
~ COMMISSION NUMBER
< DC047934
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DIANA ~)g~
Print, stamp or type name of Notary Public
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