John M. Register/Penrod Bros.City of Miami Beach Office of the City Clerk
1700 Convention Center Ddve, Miami Beach, FL 33139
Email: cityd erk@ci.miami-beach.fl.us
LOBBYIST REGISTRATION FORM
(City of Miami Beach, Ob/Code Chapter 2, Division 3, Section 2-481)
[] Check Box if an Amendment
NAME OF LOBB~ST: (Last)
(First.) DATE__QUALiFIED AS LOBBYIST
BUSINESS ADDRESS: (Number and Street) (City) (State) (Zip Code)
!
TELEPHONE NUMBER: FAX NUMBER: EMAJL:
I. LOBBYIST RTED ~
NAME OF PRINCIPAL/CL]ENT:
BUSINESS ADDRESS: (Number and Street)
(City) (State) (Zip Code)
TELEPHONE NUMBER:
FAX NUMBER: (Optional) EHAIL: (Optional)
Fill out this section if principal is a Corporation, Pamership or Trust [Section 2-482 (c)]
· NAME OF CHIEF OFFICER, PARTNER, OR BENEFIC]ARY:
· LIST ALL PERSONS MOLDING, DIRECTLY OR INDIRECFLY, A 5% OR MORE owNERSHIP [NTEREST IN SUCH
CORPORAI'ION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
Issue t6 b~ lobbied (Describe In detail):
III. CITY AGENC~ESIINDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Relationship
TV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATZON (DISCLOSE WHETHER I~OLIRI Y~
FLA ~' RATE OR OTHER.):.
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):.
2)
Pursuant to Ordinance No. 2003-3393 Amendina Miami Beach City Code ChaDter 2. Article VII. Division
Thereof Entitled "CamDaion Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited
Camoaian Contributions By Lobbyists On Procurement Issues":
Are you Iobbvina on a mresent or oendinm bid for moods, emuioment or services, or on a oresent
or mendinm award for moods, eauimment or service? [] Yes
Pursuant to Ordinance No. 2003-3395 Amendine Miami BeaCh City Code Chaoter 2. Article VI! Division
thereof Entitled 'Camoaiqn Finance Reform". Via The Addition Of Code Section 2-~90 Entitled 'Prohibited
Camoaion Contributions By,Lobbyists On Real Estate Develooment Issw~":
Are you Iobbvina on a Dendina aoolication for a Develooment Amreement with the (:ity Qr
amolication for chanae of zonina mae desianation or chanae to the City's Future Land Use Naa?
~3Yes
STGNATURE UNDER OATH:
ON OCTOBER 1sT OF EACH YEAR, EACH LOBBYZST SHALL SUBHTr TO THE CZTY CLERK A'SIGNED
STATEMENT UNDER OATH, I.Z:~ 1 lNG LOBBYZNG EXPENDTrURES TN THE cTrY OF f4ZAHI BEACH FOR
THE PRECEDING CALENDAR YEAR.
! do solemnly swear that all of the foregoing facts are true and correct and that I have read or am
familiar with the provisions contaj~ed in Section 2-.~82 of the Miami Beach, City Code as amended, and all
Signature of Lobbyist: ~ ~ ~ v~ ~/~,~'--~t , ~
LOBBY[S'r TDE~T~ON~.
~ Produced ID ~ .~ ~ '~ ~(- ~) Personally Known Form of Identification
VZT. STGNATURE AND STANP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Hiami-Dade
Swqrn to and subscribed before me
This '(~ day of '~';~. ~. 2004.
/
Signature of Public No~ry -
Print, stamp or type name of Notary Public
RegistraUon: [ ] ACCEF~mD
If rejected, state reason:
Registration fee paid:~'Yes [ ] No
DATA ENTRY DATE:
FOR CLERK'S uSE ONLY
] RF~ECTED DATE:
'~Cash [ ] Check MCR # --~
,2003 ENTERED BY:
2nd Revision 3/18/03
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