MB Jewish Community Center
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Bach, FL 33139
Emall: cltyclerk@cl.mlami-beach.fl.us
LOBBYIST REGISTRATION FORM
(City of Miami Beach, City Code Chapter 2, Division 3, Section 2-481)
o Jt5 Check Box if an Amendment
NAME OF LOBBYIST:
Diner
(Last)
Darin
(First)
(M.I.) DATE QUALIFIED AS LOBBYIST
4221 Pine Tree Drive
BUSINESS ADDRESS: (Number and Street)
Miami Beach
(City)
Florida
(State)
33140
(Zip Code)
(305\ 534-3206
TELEPHONE NUMBER:
(305\ 531-7681
FAX NUMBER:
EMAIL:
I.
LOBBYIST RETAINED BY:
Miami Beach Jewish Communitv Center
NAME OF PRINCIPAUCLlENT:
4221 Pine Tree Drive
BUSINESS ADDRESS: (Number and Street)
Miami Beach
(City)
Florida
(State)
33140
(Zip Code)
(305\ 534-3206
TELEPHONE NUMBER:
(305\ 531-7681
FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill oul this section if principal is a Corporation. Partnership, or Trust [Section 2-482 (ell
7 NAME OF CHIEF OFFICER, PARTNER OF BENEFICIARY:
7 LIST ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST
IN SUCH CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
Redevelooment of JCC Prooertv
Issue to be lobbied (Describe In detail):
III. CITY AGENCIESIINDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATRION (DISCLOSE WHETHER
HOURL Y, FLA T RA TE OR OTHER):
A) LOBBYIST DISCLOSURE:
Pro Bono
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIEST COMPENSATION):
Pro Bono
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 contained in Sect' on 2-482 of the Miami Beach City Code as
amended, and all reporting requirements
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
-!3""'.t5 Produced ID -.J) ~() - (, ~ - JL. - O'?5~- 0
Form of Identification
o .t5 Personally Known
VII. SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade
Sworn t!jland subscribed before me
This LQ:. aay o~ 2001-:$
OFFICIAL NOfARYSEAL
ULLlAN BEAUCHAMP
NOTARY PUBUC STATE OF FLORIDA
COMMISSION NO. 00109289
MY COMMISSION EXP. APR12,2006
Notary - State of Florida
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Print, stamp or type name of Notary Public
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If rejected, state reason: ___
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pATA ENTRY DATE: ~~ ENTERED BY:
Registration:
FOR CLERK'S USE ONLY
~EPTED I ] REJECTED DATE:
1 First Revision - 05-17-02