Luis Perez/Club Madonna Inc.Ob/of Hlami Beach Office of the Ob/Oerk
1700 ConvenUon Center Drive, Miami Beach, FL 33139
Emall: db/derk~d.miand-beaoh .fl .us
LOBBYIST REG:LqTRAI~ON FORM
(Ob/of Miami Beach, Ob/Code Chapter 2, Division 3, Section 2~,81)
a Check Box if an Amendment
NAME OF LOBBYT-ST: (La,c)
~L,I~ I (M [) DATE QUAI./F[ED AS LOBBY/ST
(erst) ,
BUS/NESS ADDRESS: (Number and Street) (Ob/)
' ~ ONE NUMBER: FAX NUMBER:
(stere) C~p Code)
I, LOBBYIST RETAINED BY:
~ OF pRINC/PAL/CL/ENT: '
D~:.' and Street)
TELEPHONE NUMBER:
(Ob/) (State) (Z~p Code)
FAX NUMBER: (Optional)
EMAZL: (Optional)
Fill out thEs section if prlndpal Es a CorporaUon, Partnerdnip or Truat [Section 2-482 (c)]
NAME OF CHIEF OFFICER, PARTNER, OR .BE~EFIC:~.RY:
· L/ST AU. PERSONS HOLDING, DIRECTLY OR IND~,ECTLY, A 5% OR MORE OW~ ERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSI~P OR TRUST:
*rt. SPECiFiC LOBBY ZSSUE: - - '
~°bbied-(Descflbe-in-detel,):
1'1'I. CI'TY AGENCZES/TNDMDUALS TO BE LOBBTED:
A) I~ull Name of ZndMdual/TIUe
B) RelaUonship
~V. DXSCLOSURE OF TERMS AND AMOUNTS OF LOBSYXST COMPENSA'ITON (DT~SCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER):
tO .W. ST O SO. OSO :
B) PRINCIPALS DTSCLOSURE (OF LOBBYIST COMPENSATION):
V, S~GNATURE UNDER OATH:
ON OCTOBER 1; OF EACH YEAR~ EACH LOBBYZST SHALL SUBMX'r TO THE CZ'FY CLERK A SZGNED
STATEMENT UNDER OATH, LI~ixPlG LOBBYXNG EXPENDI"rURES ZN THE CITY OF MZAMT BEACH FOR
THE PRECEDXNG CALENDAR YEAR.
! do solemnly swear that all of the foregoing facts ~ and correct and that ! have read or am
familiar with the provisions containe.~ion~Z482 o~the Hiami Beach Cib/Code as amended, and all
reporting requirements.
Signature of LobbYist:
Signature of Prindpal/ClienJ ~~
VL LOBBYXST XDENTXFXCATXON:
State of Florida, County of Miami-Dade
Swom to and subscribed before me
Th s day of /J0r-ck. 2003.
l OFFICIAL NOTARY SEAL I
LILLIAN BEAUCHAMP
NOTARY PUBLIC STATE OF FLORIDA
COMMISSION NO. DD109289
MY COMMISSION EXP. APR. 29t2006
§ign'ature of Public/Notary - State of Flfl~ida
P~int, ~m~ or ~e name of Nota~ P~lic
~ACCE FORCLF. RK'S USE ONLY ,,,~ /i ' / ~/0-~
Reglstra~o~: FTED [ ] REJECTED DATE:
2nd Revision U27/03 F:\(]f,:ER\HATL\Lobbyists\reglstratim03.doc