South Shore HospitalCity of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
Email: dtycierk@d.rniami-beach.fl.us
LOBBYIST REGI~TRATXON FORM
(City of Miami Beach, City Code Chapter 2, Division 3, Section 2-481)
Check Box if an Amendment
Rosen Harold
NAME OF LOBBYIST: (Last) (First) (M.I) DATE QUALIFIED AS LOBBYIST
407 Lincoln Road, Penthouse S.E. Miami Beach, F1 33139
BUSINESS ADDRESS; (Number and Street) (City) (State) (Zip Code)
(3050 534-4757 (305) 538-5504
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
LOBBYIST RETAXNED BY:
South SHore Hospital Foundation, Inc., a non-profit organization
NAME OF PRINCIPAL/CLIENT:
600 Alton Road, Miami Beach, Florida 33139
BUSINESS ADDRESS: (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAXL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
· NAME OF CHIEF OFFICER, PARTNER, OR BENEfiCIARY:
William Zubkoff, CEO
· LIST ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
Not applicable
SPECIF'ZC LOBBY ISSUE:
Extension of temporary Parking Lot located at 653-663 Alton Road
Issue to be lobbied (Describe in detail):
IIX. CXTY AGENCXES/INDXVXDUALS TO BE LOBBIED:
A) Full Name of Xndividual/Title B) Relationship
Planning and Zoning Department
Planning Board
ZV. DT~CLOSURE OF TERMS AND AMOUNTS OF LOBBYZST COMPENSATZON (DZSCLOSE WHETHER ltOIJRL ~
FLAT RATE OR OTHER,):.
A) LOBBYISTDISCLOSUP~: $3,500.00 Flat Fee
B) PR~NC[PAL~5 DISCLOSURE (OF LOBBYIST COMPENSA'I3ON):
z)
2)
Pursuant to Ordinance No. 2003-3393 Am~ndina Miami Beach City Code Chapter 2. Article VlI. Division 5
Thereof Entitled 'Camoaion Finance Reform" Via The Addition Of Cede Section 2-488 Entitled ~Prohibited
Camoaien Contributions By Lobbyists On Procurement [~u~s":
Are YOU Iobbvina on a Dresent or Dendina bid for aoods, eauiament or services, or on a Dresent
or oendinQ award for Qoods. eauiDment or service.? D Yes g No
Pursuant to OrdJnan;~ NO, 2003-$$9~ Amendinq Miami Beach CiW Code Chaoter 2. Article Vll Division 5
thereof Entitled ~Camoaion Finance Reform". Via The Addition Of Code Section 2-490 Entitled ~Prohibited
Camoaion Contributions By Lobbyists On Real Estate Develooment Tssues":
Are you Iobbvina on a Dendina application for a Development Aareement with the Citv or
aoDliCation for chanQe of zonina mad desiQnation or chanQe to the Citv's Future Land Use Mao?
DYes ~ N9
V. SIGNATURE UNDER OATH:
ON OCTOBER Isr OF EACH YEAR, EACH LOBBYZST SHALL SUBHIT TO THE CI'TY CLERK A S~GNED
STATEMENT UNDER OATH, LI",IING LOBBYING EXPENDITURES IN THE CITY OF M]AMI BEACH FOR
THE PRECEDING CALENDAR YEAR.
I 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~..482 of the/J~ami Beach City Code as amended, and all
reporting requirements. ~/'~ ~
Signature of Prindpal/Client: ~k.A'~"~-P[ ~~/~ ~
VX. LOBBYXST XDENTX.CA'rZON: ~'~
Produced ID
Form of Identification
Personally Known
VIZ, SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This ~ day of~, 2003.
Sigr ~ ~l~mt~4- Stat of Florida
%'~/ ...-~. c~ ~0]s~ /
~l~~ ll~n /
Print s~mp or WPe name or mo~ Public
RegistraUon: A~CCEFT~D
rejected, state mason: J
RegistraUon fee paid: ~tres [ ] No
2nd Revision 3/18/03
[ ] RE]EL II:g DATE:
F:\CLER\HATL\Lobbyists\registratJona03.doc