Charles Wayne FerrellCity Of Miami Beach Office of ~e City Clerk
1700 ConvenUon Center Ddve, Miami Beach, FL 33139
Email: cityderk~ci.miami-beach.fl.us
LOBBY:[ST REGZS'rRATION FORM
(City of Miami Beach, City Code Chapter 2, Division 3, Section 2-481)
~ Check Box if an Amendment
NAME OF LOBBYIST: (Last) (First) /~ c~, O (M.I) DATE QUALIFIED AS LOBBYIST
BUSINESS ADDRESS: {Number and Street) (City) t~t ~ (Zip Code)
LOBBYZST RETATNED BY:
NAME OF PRINCIPA~,J{IENT:
BUS[a(~ESS ADDRESS: (Number and Street)
TELEPHONE NUMBER:
(State} (Zip Code) { ,.~ ~ / ~., ~
FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill out this section If pHndpal is a Coq)oration, Partnership or Trust [Section 2-482 (c)]
· LIST ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECZFZC LOBBY ZSSUE:
l~ue to be Iobb}ed ([~ocribe in detail):
CITY AGENCTES/ZNDZVIDUALS TO BE LOBBZED:
A) Full Name of Individual/Title B) Relationship
DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYZS~ COHPENSATION (DISCLOSE WHETHER HOURL ~
FLAT RATE OR OTHER):.
A) LOBBYIST DISCLOSURE: ~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
1)
2)
Pursuant to Ordinance No. 2OO3-3393 Amendino Miami Beach City Code Chapter 2. Article VII. Division 5
Thereof Entitled ~Camoaian Finance Reform" Via The Addition Of Code Section 2-488 Entitled ~Prohibited
Camoaian Contributions By Lobbyists On Procurement Issues":
Are you Iobbvina on a present or oendina bid for =oods, eeuim~ent or services, or on a oresent
or oendine award for aoods, eeuioment or service? [3 Yes Ig'lo
Pursuant to Ordinance No. 2003-3395 Amendina Miami Beach City Code ChaDter 2, Article VII Division S
thereof Entitled "Camoaian Finance Reform". Via The Addition Of Code Section 2-490 Entitled "Prohibited
Camoaian Contributions Bv Lobbyists On Real Estate Deveiooment Issues":
Are you Iobbvina on a oendina aaolicaUon for a Develooment Aareement with the City or
aoolicatim~for chanae of zonina moo desianation or chanae to the City's Future Land Use Moo?
aYes ~o
V. SIGNATURE UNDER OATH:
ON OCTOBER Is~ OF EACH YEAR, EACH LOBBY[ST SHALL SUBM/T TO THE C/TY CLERK A SZGNED
STATEMENT UNDER OATH, LI~iiNG LOBBY[NG EXPENDITURES TN THE CITY OF M[AM! BEACH FOR
THE PRECEDZNG CALENDAR YEAR.
! do solemnly swear that all of the foregoing facts are true and correct and that I have read or am
familiar with the provisions contained in Section 2-482~ef the Miami Reach City Code as amended, and all
reporting requirements.
Signature of Lobbyist: ~/'"~.~ ///---J' ~ '
Signature of Principal/Client: v~-~_ v~_ ~C--~-~~'--I L~ ~
LO/BBY~ST IDENTiFiCATiON:
~Produced ID pb~ ~ctO-
Form of Identification
V~I. SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This o.O~ day of ~ ,2003.
OFFICIAL NOTARY SEAL
LILLIAN BEAUCHAMP
NOTARY PUBUC STATE OF FLORIDA
COMMISSION NO. DD109289
MY COMMISSION EXP. APR. 29,2006
Personally Known
Signature of Publi{: Notary - State of Flor(da
Print, stamp or type name of Notary Public
Registra~on: [ At~]~CCEPi ED
If rejected, state mason:'~J'
Registration fee paid: [-,~Yes [ ] No
DATA ENTRY DATE: /_~/?~(..~
/
2nd Revision 3/18/03
FOR CLERK'S USE ONLY
REJECTED
DATE:
[ ]Ca~ £ ]check ~CR# ' ~ ~ ./ ~ ~ ~
· 2003 ENTERED BY: ~A_ ~ /~
~,'l-
F:\~'~ATL\Lobbyists\registrationa03.doc