Victoria Marcos/Sarmiento AdvOb/of Miami Beach Office. of the Ob/Oerk
1700 Convention Center Drive, Miami Beach, FL 33139
Email: db/derkl~.mlami-beaCh.fl.us
LOBBY/ST REGISTRATION FORM
(Oty of Miami Beach, Ob/Code Chapter 2, Division 3, Section 2-481)
Q Check Box if an Amendment
NAME OF LOB (La~) (n~)
BUSINESS ADDRESS: (Number and Street2 (Ob/)
TELEPHONE NUMBER: - ( FAX NUMBER:
"-' (M.I) DATE QUALIHc. u ~ LOBBY/ST
(S~at~) (Zip Code)
I. LOBBY/ST RETAZNED BY:
NAME OF PRINCIPAl/CLIENT:
- (Number and Street) (ab/) c~ ' (S~te)
TELEPHONE NUMBER: FAX ~JMBER: (Optional)
(Zip C~e)
-
EMAIL: (OpU~q~ai)
r-
Fill out this section if principal is a CorporaUon, Partnership or Trust [Section 2-482 (c)]
·
· LIST ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
O3RPORATION, PARTNERSHIP OR TRUST:
I'Z. SPEC]:F]:C LOBBY zsSUE:
Issue to be lobbied (Describe Iffdetail):
11'I. CITY AGENCZES/]:NDI'VZDUALS TO BE LOBB,TED:
A) Full Name of lndividual/'nUe
Relationship
XV. DXSCLOSURE OF TERMS AND AMOUNTS OF LOBBYX~r COMPENSATXON (DTSCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER): ~:~ :/,.~ ~07/~~) ~~ 0 -,~,~>
A) LOBBYIST DZSCLOSURE: J"') AA
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
V, ~GNA~RE UNDER OATH:
ON ~OBER 1~ OF ~CH ~AR~ EACH LOBB~ SHALL SU'BN~ TO THE ~ CLERK A S~GNED
~ATE~E~ UNDER OA~ ~NG LOBBING EXPEND~URES ~N THE C~ OF ~I B~CH ~R
THE PRECEDING ~LENDAR Y~
! do solemnly swear that all of ~ foregoing facts are true and correct and that ! have read or am
familiar with the provisions cor~ained in Section 2-482 of the Miami Beach City Code as amended, and all
reporting requirements.
signature of LobbY ~i~."~..--~--~-.~~'~ %, i' '
Sig~ature of Prindpal/Client:
w.a/~ProducedLOBBYXST XDENTZFXCATXON:/~~ ~\/ .
TO ~)L ~ V,-~ ~/o '- 5 q~- {o1,'-' IO~, -[]) [] Personally Known Form of Identification
State of Florida, County of Miami'Dade
'Sworn to and subscribed before me
This ~ q/~,day of ~4 ~'/~ ~, 2003.
S~GNATURE AND STAHP OF NOTARY OR DEPUTY CLERK: I 0F.Cb~'NOTAR¥ SF-AL I
I LILLIAN BEAUCHAMP'. ' I
I NOTARY PUBLIC S'rATE OF FLORIDA !
I CO~MmS~ON NO. Dm0~ I
~ ', I M,~,~MISSIONEXP. Al~R. 29,2006 !
~i~ature o~ ~u~Notary- State o(FIodda
Prin~, Stamp or type name Of Notary Public
RegistraUon: ~'ACCEPTED [
Registration fee paid: ~s [ ] No/
DATA ENTRY DATE: /./...[ '~C( [r._~
L !
2nd Revision 1/27/03
..
FOR CLERK'S USE ONLY
,2003 ENTERED BY: ~'