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Pablo Perez/Club Madonna, Inc.Ob/of Miami Beach Office of b~e Ob/Oe~k 1700 ConvenUon Center Drive, Miami Beach, FL 33139 Emalh cityderk~ct, miami-beach.fl.us LOBBY/ST REGISTRATION FORM (Oty of Miami Beach, Ob/Code C~apter 2, Division 3, Sect]on 2~181) Q Check Box if an Amendment NAME OF LOBBY~'.~ (Last) BUSINESS ADDRESS: (Number and Street) 'T'ELFPHONE NUMBER: (Rrst) (~t,/) FAX NUMBER: (M.I) DATE QUA, Ltl-ted.; AS LOBBYIST (State) ~p Code) X, LOBBY/ST RETAZNED BY: NAME OF pP. INCtpAL/CLiENT: BUSINESS ADDRESS: (N~ and Street) (aw) (State) TELEPHONE NUMBER: FAX NUMBER: (OpUonal) EMATL: (Optional) Fill out this section if principal is a CorpomUon, Partnership or Trust [Section 2.-482 Cc)] · NANE OF CHZEF OFPTCER, PARTNER, OR BENERC[ARY: · I~ST ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST [N SUCH CORPORAT[ON~ PARTNERSHIP OR TRUb-I': SPECiFiC LOBBY LSSUE: issue to 1Se lobbied (Describe in detail): XXX. ~ I '( AGENCiESIXNDXVXDUALS TO BE LOBBXED: A) Full Name of ZndMdual/TIUe B) Relationship ~V. DI'SCLOSURE OF TERMS AND AMOUNTS OF LOBBY'~'T COMPENSA'I'~ON (DI'SCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): ON OCTOBER IsT OF EACH YEA~ EACH LOBBY~SI' SHALL SUBHIT TO THE ~ ~ t' CLERK A S~GNED STATEHENT UNDER OATH, LI:~,-NG LOBBY]lNG E~iDTI'URES 1'N THE CI'TY OF H~AH! BEACH FOR I do solemnly swear that all of~e foreg,~ ng fa~gts are~rue and correct and that I have read or am familiar with the provisions co~taiped j,q'~ ectiq~g 2-~82 of the Miami Beach City Code as amended, and all reporting requirements. ~/~ //~ Slgnature of LobbYist: 'l / ~/Jr~) I~~'''' · ~'/Produced ID p~L.. 1°(~2.O _/oLO- L~© -~'- © [] Personally Known Form of Tdentification VI/. S/GNATURE AND STAMP OF NOTARY OR DEPUTY CLERK: ~:L~'~ ~ (~% -.~'~"~- ~,Z- I(~-- O. State of Rorida, County of Miami-Dade Sworn to and subscribed before me This iq'~ dayof ~i£~'.~ .2003. ' i OFFICLAL NOTARY SEAL I I ULU~ B~UC~Me I S~nature of Publ~ Notary - State of Florida I ~Y ~o~ ~xP. ~. ~.. I Print, ~mp or ~pe name of Nota~ ~blic