Steven Marin Atlantic Dental In RECEIVED
City of Miami Beach Office of the City Clerk
1700 ConvenUon Center Drive, Miami Beach, FL 33139 03 j~.~ y 20 Pi~ 3:30
Emaih cityderk@ci.miami-beach.fl.us
LOBBYZST REGISTRATION FORM .CITY CLER~('$ OFFICE
(City of Miami Beach, City Code Chapter 2, Division 3, Section 2-q81)
o Check Box if an Amendment
NAME OF LOBBYIST: (Last) (First)
(M.I) DATE QUALTFIED AS LOBBYIST
,44 ,' ,~,~ ,' FL
BUSINESS ADDRESS: (Number and Street) (City)
70 (/' ~7/- ~2 ? 305 _ ~ 71-]-7//
TELEPHONE NUMBER: FAX NUMBER:
(State)
(Zip Code)
EMAIL:
i'. LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
BUSINESS ADDRESS: (Number and Street) (City)
?O~-Wl~-~lll ~73 ~O~-
~LEPHONE NUMBER: F~ NUMBER: (Optional)
(St/ate) (Zip Code)
EMAIL: (Optional)
Fill out this section if prindpal is a Corporation, Partnership or Trust [Section 2-482 (c)]
· NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
· LIST ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
TT. SPEC/F~C LOBBY !:~JE:
Issue to be lobbied (Describe in detail):
tTr. C/TY AGENCIES/ZNDMDUALS TO BE LOBBTED:
A) Full Name of Individual/liUe B) RelaUonship
FLAT RATE OR OTHER.):
A) LOBBYIST DISCLOSURE: ~1~"'~ /-4~-~ /J~O0
B) PRINCIPAL~ DISCLOSURE (OF LOBBY[bT
2)
Pursuant to Ordinance No. 2003-3393 Amendino Miami Beach City Code ChaDter 2, Article V[][. Division 5
Thereof Entitled "Camoaion Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited
Campaiqn Contributions By Lobbyists On Procurement Issues':
Are you Iobb¥imi on a present or aendinQ bid for lioods, e~uiDment or services, or on a Qresent
or pendinq award for Dood$, e~uiDment or service? ~,~_~) No
Pursuant to Ordinance No. 2003-3395 Amendina Miami Beach City Code Chapter 2. Article V~! Division 5
thereof Entitled "Campaiqn Finance Reform", Via The Addition Of Code Section 2-490 Entitled "Prohibited
Campaiqn Contributions By Lobbyists On Real Estate Develooment [ssues":
Are you lobbying on a aendina aaolicetion for a Development Aareernent with the City or
aaalicet~ for chanae of zonimi mad desiflnation or chanqe te the City's Future Land Use MaD?
V. SIGNATURE UNDER OATH:
ON OCTOBER '1~' OF EACH YEAR, EACH LOBBY[ST SHALL SUBMTr TO THE cTrY CLERK A St'GNED
STATEMENT UNDER OATH, I. ZSTTNG LOBBYZNG EXPENDTrURES t'N THE CTFY OF MZAM'I' BEACH FOR
THE PRECEDZNG CALENDAR YEAR.
! do solemnly swear that all of the foregoing facts are true and correct and that ! 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:
LOBBY]~' ZDENTJFZCA'I1ON:
Produced ID
Form of Identification
V~Z. SZGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade
Swor~ to nnrl ~Hh~crihed hefnre me
2003.
Personally Known
Signature of Pul"i;'lll
II1'
Print, stamp or
mR O'RK'S USE O. Y
RegistraUon: .~AC:CEPTED [ ] REJECTED DATE:
if rejected, state reason:
RegistraUon fee paid:~es [)No [ ]Cash [x~heck MCR#
DATA ENTRY DATE: ~ 2003 ENTERED BY:~_ ~ ~
2nd Revision 3/18/03 F:\~HATL\Lobbyists\registTat~ona03.doc
· 65/05/2003 15:46 FAX 3054431926
ADI
Atlantic Dental, Inc.
Owners with 5% or mom
002/002
Dr.
Mr.
CFO
Name
~. Fernandez
Robert
IPedro Jimenez
James Pinto
~F'rost
Address2
Address t
5 Tahiti Beach island Road
3-~51 St. Gaudens
~710 SW 99 Terrace
~re Drive Suite 725
366 Round Hill ~
_4400 Biscay_ne Boulevard
~ FL 33143
~ve FL 33133
~ FL 33156
Miam~ FL 33133
~ CT O6831
~ FL.L~_~33137
Perc~::i ~ge
Owner,.-' hip
50.¢7
6.67
6.6'/
6.6 i'
6.6/'
Last Update: 4/7/03