MB Jewish Community Center
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aty of Miami Beach Office of the aty Oerk
1700 Convention Center Drive, Miami Beach, FL 33139
Emall: dtyderk@d.miami-beach.f1.us
LOBBYIST REGISTRA110N FORM
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(City of Miami Beach, City Code Chapter 2, Division 3, SectIon 2-4Bl)
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NAME OF LOBBYIST: (Last) (Arst) (M.I) DATE QUAUFIED AS LOBBYIST
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BUSINESS ADDRESS: (Number and Street) (CiM (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAljCUENT:
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BUSINESS ADDRESS: ( umber a Street) (aty) (State)
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TELEPHONE NUMBER: FAX NUMBER: (Optional)
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(Zip Code)
EMAIL: (Optional)
Fill out this section If prindpalls a Corporation, Partnership or Trust [SectIon 2-482 (e)]
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;
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II. SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
IU, CITY AGENCES/INDMDUALS TO BE LOBBIED:
'" Full Name of Individual/Title B) ltelatloMhlp
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PLA rvV'~ e, (}"f'I. (l..Jl
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IV..... DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FL~ATE OR OTHER):
A) LOBBYIST DISClOSURE:
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B) PRINCIPAL'S DISClOSURE (OF LOBBYIST COMPENSATION):
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Y. SIGNATURE UNDER OATH:
ON OCTOBER 1ST 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.
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I do solemnly swear that all of the foregoing facts ate 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:
Signature of Principal/Client:
VI, LOBBYIST IDENTIFICATION:
~roduced ID
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Form of Identification
,; Personally Known
VII. SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami~Dade
Sworn to and subscribed before me .3
This / (J rt, day of ~ ,20nf.
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SI ature of P lie Notary - State of Florida
L/lft'u"/ koc.t..~~
Print, stamp or type name of Notary Public
SEAL
-LiLLIAN BEAUCHAMP
NOTARY PUBUC srATEOF FLORIDA
COMMISSION NO. DDl09289
MY COMMISSION EXP. APR. 29~
Registration:
[ ~PTED
FOR CLERK'S USE ONLY
[ ] REJECTED DATE:
1/(010 ~
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If rejected, state reason: ...-.
Registration fee paid: ['-f'fes [ ] No
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DATA ENTRY DATE: ~ Z062
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1 First Revision - 05/17/02