Claire Tomlin - The Market Co.
~
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
Email: cityderk@d.mlami-beach.f1.us
LOBBYIST REGISTRATION FORM
-
(City of Miami Beach, City Code Chapter 2, Division 3, Section 2-481)
o Check Box if an Amendment
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TELEPHONE NUMBER:
,:;o65~200f:>?~
FAX NUMBER:
(State) (Zip Code)
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EMAIL:
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I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAljCUENT: \
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BUSINESS ADDRESS: (Number and Street)
(City)
(State)
(Zip Code)
TELEPHONE NUMBER:
FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill out this section If principal Is a Corporation, Partnership or Trust [Section 2-482 (c)]
. NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
. UST ALL PERSONS HOLDING, DIREcn. Y OR INDIREcn. Y, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR mUST:
U. SPEOFIC LOBBY ISSUE:
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Issue to be lobbied (DeScribe in detail): .. "
UI. aTY AGENOES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Relationship
'lV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSA nON (DISCLOSE WHETHER HOURL Y,
FLATRATEOR OTHER): ~ . (
A) LOBBYIST DISCLOSURE: 15. /J?nJ / r .
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
41
1) Pursuant to Ordinance No. 2003-3393 Amendina Miami Beach City Code Chaoter 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":
:~:~:i~Gb=:~oio: :o,:::.n::~i:'''ed~~:rb~:~~:o~~a~i::ent or services. or on a Dresent
2) Pursuant to Ordinance No. 2003-3395 Amendina Miami Beach City Code Chaoter 2. Article VII Division 5
thereof Entitled "Camoaian Finance Reform". Via The Addition Of Code Section 2-<190 Entitled "Prohibited
Camoaian Contributions BY Lobbvists On Real Estate Develooment Issues":
Are YOU lobbvina on a Dendina aDDlication for a Develooment AGreement with the City or
:::~ for chanGe of zoninG maD desianation or chanGe to the City's future Land Use MaD?
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE cnv CLERK A SIGNED
STATEMENT UNDER OATH, U5nNG LOBBYING EXPENDITURES IN THE cnv OF MIAMI 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 2-482 of the Miami Beach City Code as amended, and all
reporting requirements.
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Signature of lobbyist:
Signature of Principal/Client:
VI. LO.IYIST IDENTIFICAnON:
[J Produced 10
~rSOnallY Known
Form of Identification
VII. SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade
Sworn to and SUbscri~.e
This ?, () "'f'!, day of 2003.
OFFICIAL NOT ARysEAL
LILLIAN BEAUCHAMP
NOTARY PUBLIC STATE OF FLORIDA
COMMISSION NO, DDl09289
MY COMMISSION EXP, ~_~':,?9?f!!)L
Print, stamp or type name of Notary Public
Registration: ~D
If rejected, state reason:
Registration fee paid: [ [ J No
DATA ENTRY DATE: ~ ,~ 6
2nd ReviSion 3{18{03
FOR CLERK'S USE ONLY ~ /
[ ] REJECTED DATE: Cf;30 D <-
, ,.
.2003
ENTERED BY:
A TL \Lobbyists\registrationa03.doc