Jeffrey Bass/ Jerry BlairCity of Miami Beach Office of the City Clerk
1700 Convention Center Ddve, Miami Beach, FL 33139
Email: dtyderk@ci.miami-beach.fl.us ,,
LOBBYTST REGZSTRATZON FORM , ,. :. ,
RECEIVED
(City of Miami Beach, City Code Chapter 2, Division 3, Section z-48~3 JUL 3 0 PH [,: :3 2
~C ~eck Box ir an Amendment "%--- C~C L Ei~K' S 0~,CE
NAME OF LOBBYIST: (Last) e (First)
BUSINESS ADDRESS: (Number ~nd Street) (City)
/ (M.I) DATE QUALIFIED AS LOBBYIST
(State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
LOBBYIST RETAINED II}Y:
NAME OF PRINCIPAL~I IENT:
BUSINESS ADDRESS: (Number and Street) (City) (State) (Zip Code)
TELEPHOI~E NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section if principal is a Corporation, Parthersh p or Trust [Section 2-482 (c)]
· NAME OF CHIEF OFFICER, PARTNER, ~0~ BENEF[GIARYz
· LIST ALi PE~t~;ONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
Issue to. be lobbied (Describe in detail):
III. CZTY AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Relationship
DZSCLOSURE OF TERMS AND AHOUNTS OF LOBBYT-ST COMPENSATION (DZSCLOSE WHETHER HOURI
FLAT RATE OR OTHER):. ,
1) Pursuan~e'(o Ordinaflce No. 2003-3393 Amendina Miami Beach City Code Chaoter 2. Article VII. Division 5,
Thereof Entitled ~Camoaien Finance Reform" Via The Addition Of Code Section 2-488 Entitled ~Prohibited '
Camoaien Contribut, ions Bv LObbyists On Procurement [ssues": . _ ~,
2)
Are you Iobbvina on a =resent or Dendina bid for aoods, eauJoment or services, or on a nresent
or aendina award for aeods, eeuinment or service? O Yes ~i[N0', -'
Pursuant to Ordinance No. 2003-3395 Amendina Miami Beach City Code ChaDter 2. Article VI! Division 5
thereof Entitled ~Camoaian Finance Reform". Via The Addition Of Code Section 2-490 Entitled "Prohibited
Camoaian Contributions By Lobbyists On Real Estate Develooment Issues":
Are you Iobbvina on a Dendina annlication for a Develonment Aareement with the City or
annlicalllon for chanae of zonina man desianation or chanae to the City's Future Land Use I¥1an?
SIGNATURE UNDER OATH:
O1~ O~OBER IsT OF EACH YEAR, EACH LOBBYZST SHALL SUBMTT TO THE ~z i Y CLERK A SZGNED
STATEHENT UNDER OATH, tSS i LNG LOBBYING EXPENDTTURES IN THE cTrY OF I~I~B,I~II 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 Se~,~,i~82 of the Hiami Beach City Code as amended, and all
reporting requirements.~~~
Signature of Lobbyist:
SlgnatureofPrlnclpal/Chent~/"~:::~:~[ ~1 (~J~cf~ ~7A.42.,~ ~$¢~ ~-~ ~-~'~[)'
VZ. LOBBYZST ,DENTiFZCATZO.:
Produced ID
Form of Identification
SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miam[-Dade ' ;.
Sworn_to and subscribed before me '
This ZO't~'day of--'~"""~t~,,~ , 2003.
/~rsonally Known
Regisba;don: -~ACCEPTED
Regislraldon fee paid: ~L~Yes [ ] No
DATA ENTRY DATE:
2nd Revision 3/18/03
FOR CLERK'S USE ONLY
DATE:
,2~3 E~RED BY:
F:~C~R~HA~Lobbyi~r~i~a~ona03.d~