HomeMy WebLinkAboutLa Gorce Country Club
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City of Miami Beach Office of the City Cierk
1700 Convention Center Drive, Miami Bach, FL 33139
Email: cityclerk@ci.mlami-beach.fl.us
LOBBYIST REGISTRATION FORM
(City of Miami Beach, City Code Chapter 2. Division 3, Section 2-481)
o 6S Check Box If an Amendment
NAME OF LOBBYIST:
Lull
(Last)
Jack
(First)
(M.I.) DATE QUALIFIED AS LOBBYIST
BUSINESS ADDRESS:
1900 Tlaerhill Ave.
(Number and Street)
305-856-0138
Miami
(City)
FL
(State)
305-856-2765
33133
(ZIp Code)
TELEPHONE NUMBER:
FAX NUMBER:
EMAIL:
I.
LOBBYIST RETAINED BY:
La Gorce Countrv Club
NAME OF PRINCIPAUCLlENT:
BUSINESS ADDRESS:
5685 Alton Rd
(Number and Street)
Miami Beach
(City)
FL
(State)
33140
(ZIp Code)
305-866-4421
305-37 4-0804
FAX NUMBER: (Optional)
EMAIL: (Optional)
TELEPHONE NUMBER:
Fill out this section If principal Is a Corporation. Partnership, or Trust [SecUon 2-482 (cll
? NAME OF CHIEF OFFiCER, PARTNER OF BENEFICIARY:
? LIST ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST
IN SUCH CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
Desion Review Aooroval for Maintenance Bulldinas and Restroom FacilitY
Issue to be lobbied (Describe in detail):
III. CITY AGENCIESnNDIVIDUALS TO BE LOBBIED:
A) Full Name of IndlvlduallTltle
B) Relationship
None
None
if'
.
. ~ ........ ,~
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATRION (DISCLOSE WHETHER
HOURL Y, FLA T RA TE OR OTHER1J
A) LOBBYIST DISCLOSURE: ---=...J.>O /~
,
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIEST 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
PRESEDING 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 conta' d' Section 2 of the Miami Beach City Code as
amended, and all reporting re Ir e s.
Signature of Lobbyist:
VI.
o ,or Produced 10
Form of Identification
~ Personally Known
VII. SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade
Swornjo and subj>cribed before me
This !L day of N oV' ,2002.
G) BErn lleRENA
MY COMMISSION 11 DO 08llQ87
EXPIRES: Febluary 27, 2008
I~ARY FL NoIory _ & BoncIng, Inc.
.
Print, stamp or type name of Notary Public
Registration:
FOR CLERK'S USE ONLY
~CEPTED [ ] REJECTED DATE: It - l <6 -0 '2- Het1
If rejected. state reason:
Registration fee paid: [l.{Yes [ ] No ') 51 ".,. ~
[J c..h I I"*" MCR' ~ 4
pA TA ENTRY DATE: 1.1 ,It rj . 2002 ENTERED BY .-J
1 First Revision - 05-17-02
~
- ~
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSA TRION (DISCLOSE WHETHER
HOURL Y, FLA T RA TE OR OTHER):
A) LOBBYIST DISCLOSURE: ..I I,b J h<
I
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIEST COMPENSATION):
V. SIGNATURE UNDER OATH:
ON OCTOBER 11T 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
PRESEDING 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 of Lobbyist:
/Slgn.,"..~Priocipa"CJ;.n" ~~~, V~
VI. LOBBYIST IDENTIFICATIO .
o .II! Produced 10
Form of Identification
?personallY Known
VII. SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
-~n_d.\lIlONNl/.l_ ~"~'iIf.~
m g.l8QW8OeQ :S3tlldX3 ; . t~
StB9Q6 :xl, NOISSlI'll'lOO AW i-i i..
1'iIOlM'l NNV 8fTlAHd ~L~
'''I~''''
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This I ~ay of NOIJuM~02.
h<-~
~ure of Public Notary - State of Florida
- thl.o\ 111'5 An0 mAR.c.io..L..
Print, ~p or type name of Notary Public
PHYlUS ANN MAACIAl
MV COMMISSION II CC 986245
EXPIRES: I)eCeI11bel5, 2Oll4
ao___P",,",Unde"""lS
FOR CLERK'S USE ONLY
Registration:
[ ) ACCEPTED [ ] REJECTED DATE:
If rejected. state reason:
Registration fee paid: [ ] Yes [ ) No
[ ] Cash [ ) Check MCR #
DATA ENTRY DATE:
1
. 2002 ENTERED BY:
1 First Revision - 05-17-02