HomeMy WebLinkAboutLucia Penrod City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
Emaih cityderk@ci.miami-beach.fl.us
LOBBYIST REGZSTRATZON FORM
(City of Miami Beach, City Code Chapter 2, Division 3, Section 2-481)
o Check Box if an Amendment
NAME OF LOBBYIST: (Last) -'~
BUSINESS ADDRESS: '('Number and Street)
TELEPHONE NUMBER:
(First) (M.I)
(Ob/) (State)
FAX'IqUMBER:
DATE QUALIFIED AS LOBBYIST
(Zip Code)
EMAIL:
LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
BUSINESS ADDRESS: (Nur~ber and Street)
TELEPHONE'~IUMBER:
(ow) (state)
FAX NUMBER."'(Optional)
(Zip Code)
EMA[L: (Optional) ·
Fill out this section If principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
* NAME OF CHIEF OFFICER, PARTNER, OR BENEF]CIARY:
· I-[ST ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MoRE OWNERSHIP INTEREST IN SUCH
CORPORATZON, PARTNERSHIP OR TRUST:
II. SPECIFZC LOBBY ISSUE:
Issue to be lobbied (Describe in detail):
Ill. ClTY'A~GENC~ES/[NDI'V/DUALS TO BE LOBBZED:
A) Full Name of Zndividual/Tltie B) Relationship
I
DZSCLOSURE OF TERMS AND AMOUNTS OF LOBBY[ST COMPENSATZON (DZSCLOSE WHETHER t'IOI./RL
FLAT RATE OR OTHER):,
A) LOBBYIST DISCLOSURE:
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
1)
2)
Pursuant to Ordinance No. 2003-3393 Amendino Miami Beach Cib/Code Chapter 2, Article Vii, Division 5
Thereof Entitled "CamDaian Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited
CamDaian Contributions By Lobbyists On Procurement ISSues":
Are you Iobbvina on a present or ~endina bid for aoods, eauioment or services, or on a present
or nendina award for aoods, eauiDment or service? [] Yes
Pursuant to Ordinance No. 2003-3395 AmendinQ Miami Beach City Code Chaoter 2. Article V[I Division
thereof Entitled "Camoaion Finance Reform", Via The Addition Of Code Section 2.4c~0 Entitled "Pr0hibited
Camoaian Contributions Bv Lobbyists On Real Estate DeveloDment ]Issues':
Are you Iobbvina on a Dendina aDDlication for a DeveloDment Aareement with the City ;r
aDolicatioff'for chanae of zonina mad desianation or chanae to the City's Future Land Use HalT?
~Yes g"~lo
V. SZGNATURE UNDER OATH:
ON OCTOBER IsT OF EACH YEAR, EACH LOBBYZST SHALL SUBMZT TO THE CZTY CLERK A SZGNED
STATEMENT UNDER OATH, LZST~NG LOBBYZNG EXPENDZTURES ZN THE C:ZTY OF MZAH! BEACH FOR
THE PRECEDI'NG 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.
Signature of Lobbyist:
Principal/Client:
Signature of __
m/Produced ID /Z2('f-3 - J'~; - J~'~ -- ~ -- o Personally Known Form of Identification
VZZ. SZGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade
Sworn to and subscribecJ before me
This ~ _r-A day of ~/~z.&5~ 2004.
Signature of Public Notary - State of .l~l L,~.m ~,.m~
My Cornmiss/o~ 00002020
Print, stamp or ~pe name of No~ Public
RegistraUon: [ ] ACCEPTED
If rejected, state reason:
RegistraUon fee paid:~es [ ] No
DATA ENTRY DATE:
FOR CLERK'S USE ONLY
M C~sh [ ] C~k MCR ~ ~ ~ ~
,2003 ~ ~:
2~ R~on 3/18/03
F:~C~R~LL~E~B~b~i~i~Uona~.d~