HomeMy WebLinkAboutLucky Strike Miami LLC City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FI_ 33139
LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat
or modification of any ordinance, resolution, action or decision of any commissioner; any action, dedsion, recommendation of the
Ob/ Manager or any city board or committee; or any action, decision or recommendation of any city personnel defined in any
manner in this section, during the time pedod of the entire decision-making process on such action, decision or recommendation
that foreseeably will be heard or reviewed by the city commission, or a db/board or committee. The term specifically includes the
principal as well as any employee engagedin lobbying activities. The term 'Lobbyists" has specific exclusions. Please refer
to Ordinance 2004-3435.
__,/.~E OF LOBBYIST: (Last)
I~USINESS NAME AND ADDRESS
TELEPHONE NUMBER:
(Number and Street) (City)
FAX NUMBER: EMAIL:
i. LOBBYZST RETAINED BY:
N/~4E OF PR~NQPA~CUENT:. / . / -- .,~, /--~' /d.~,,.¢
Bb'S'~IESS NAME AND ADDRESS A~lumper and Str) (City) -- / (state) T (Zip
4L/¥/7
TELEPHONE'NUMBER: FAX NUMBER: (Optional) EMA[L: (Optional)
Fill out this section If principal is a CorporaUon, Partnership or Trust [Section 2-4~2 (c)]~.~
· NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~ J~'~l ~7~
· IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II.
Issue to be lobbied (Describe in de~il):
III. ~/?,CITY AGENCIES/INDIVIDUALS TO BE LOBBIEE
A) Full Name of J/ndividual/TiUe .... /
SPECIFIC LOBBY ISSUE:
B) Any Financial, Familial or Professional Relationship
ZV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSAI'JON (DISCLOSE WHETHER HOURL
FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required r'~~ '
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
Yes ~ Are you reoresentina a not-for-oru;;~ corooration or entity without spec!a! com~ensaaon or
~ Pursuant to Ordinance No. 2004-3435.
1) Pursuant to Ordinance No. 2003-3393 Amendinq Miami Beach Cib/Code Chaoter 2. Article VII. Division 5
'/ Thereof Entitled "CamoaiQn Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited
o: es"
~CamoaiQn Contributions By Lobbyists On Procurement Issu :
Yes Are you ;obbv~na on a or~c-~t or oendina bid for aoods, eauioment or servk~, or on a present
Pr oendinq award for aoods, eauioment or service?
2) Pursuant to Ordinance No. 2003-339S Amendinq Miami Beach City Code Chaoter 2, Article VII Division 5
thereof FntiUed Camomqn F nance Reform, ¥~a T Addition Of Code Section 2-490 Entitled "Prohibited
~Camoai~n Contributions By Lobbyists On Real Estate Development Issues":
Y N : A o I in n n in ii i nf r D v o men A m i t i r
· · ' L M
ii aionf r h n fzo in a d ' n , n r h n , u ·
V. SZGNATURE UNDER OATH:
ON OCTOBER 1s~ OF EACH YEAR, EACH LOBBYZST SHALL SUBMZT TO THE CZTY CLERK A SIGNED
STATEMENT UNDER OATH, LISTZNG LOBBYZNG EXPENDZTURES, AS WELL AS COMPENSATZON
RECEIVED, IN THE CTTY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
DURING THE
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDTrURES OJ~-COMPENSATION
REPORTING PERZOD.
~ / Signature of Lobbyist
or)
~ .... ?- ....... ~* ~" ~; ~e fore~oinn facts are true and correct and that ! have read or am
,. Z oe"sote~nly 5wCa~ u~a~ o,, ,~. -- = = · · · all reporting
~t~-~farnJ~r v~.~h the provisions contained in Section 2-~,82 of the Fham~ Beach CRy Code and
r..~Sig ~u r~_~f Lobbyist'
ign~'~ture~ef Principal Cli
c~ PRINCIPAL. IOENI'~F~CAT~ON;
VI. LOi~BY~ST IDENTIFICATION:
Produced ID.
Form of Identification
[ eV~rsonally known (Lobbyist)
Form of Identification
Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, Count~ of Miami-Dade
Sworn to and subscril~d before me /
Notarization of Lobbyist's signature
State of Florida, County of Miami-Dade
Sworn and subscribed before me z
Notarization of Principal's signature
FOR CLER ' U E ONLY ' .
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'LAon~bUyaiistR~geijis[rtart~t°i~n~eFe~rmL recVJei've~dLandJv'~r'~fied~y: '~' ~.~,) , '
Revised 02/10/0~- F: CLER\ALL\RA-~,IA-M\LOBBY[ST\LOBBYIST FORM 0~