Randall Hilliard/Gold Star Prkg
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
Email: cityclerk@d.miami-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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NAME OF LOBBYIST: (Last) (First) (M.!) DATE QUAUFIED AS LOB8YIST
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BUSINESS ADDRESS: (Number and Street) (City) ) / (State)' (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL: CovYt
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(State)
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(Zip Code)
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:
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. UST ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
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II. SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail): \
III. CITY AGENClES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Rel~onshlp
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLA T RATE OR OTHER):
A) LOBBYIST DISCLOSURE: _1> I. c<;)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):J r .(!) ()
1) Pursuant to Ordinance No. 2003-3393 Amendina Miami Beach Citv Code Chaoter 2. Article VII. Division 5
Thereof Entitled "Camoaian Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited
Camoaian Contributions Bv Lobbvists On Procurement Issues":
2) Pursuant to Ordinance No. 2003-3395 Amendina Miami Beach Citv Code Chaoter 2. Article VII Division 5
thereof Entitled "Camoaian Finance Reform". Via The Addition Of Code Section 2-490 Entitled "Prohibited
Camoaian Contributions Bv Lobbyists On Real Estate Develooment Issues":
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V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, USTlNG LOBBYING EXPENDITURES IN THE CITY 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 r:ntained in Section 2-482 of the Miami Beach City Code as amended, and all
reporting requirements. _ _
Signature of Lobbyist:
Signature of Principal/Client: ~-
VI. LOBBYIST IDENTIFICATION:
IB" Produced ID
Personally Known
Form of Identification
VII. SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade
S>.om to and SUbscri~:~.e if2.. ~
This I 2 day of 2004. ~ ~
r........ '."""~"'"""''''''''''''''''''' Signature of Public Notary - State of Florida
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~\0}$3~t~ Bonded"""(ICIllllJ112l14 Print, stamp or type name of Notary Public
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........ ...........................
FOR CLERK'S USE ONLY
Registration: [ ...(ACCEPTED
] REJECTED
DATE:
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If rejected, state reason:
Registration fee paid: [~es [ ] No [ sh [ ] Check
DATA ENTRY DATE: J I' 'Z... i 0 L~ ENTERED BY'
2nd Revisi /18/03
F: \CLER\$ALL \EUZABET\Lobbylist\registrationa04.doc