Elaine Rosen/MB Watersports
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, Fl33139
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LOBBYIST REGISTRATION FORM
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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, decision, recommendation of the
City 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 period 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 city board or committee. The term specifically indudes the
principal as well as any employee engaged In lobbying activities. lbe tenn "LDbbylstsn h.. ~ exclulllon.. Pie... refer
to Ordln.nce 2004-3435.
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NAME OF LOBBYIST: (Last) (First) (M.I)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
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NAME OF PRINOPAl/Q.IENT:
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(City)
Sor- d'bI <f3(f/
FAX NUMBER: (Optional)
If--
(State)
331.
(Zip Code)
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TELEPHONE NUMBER:
EMAIL: (Optional)
Fill out this section If prlnclp.lls. Corpor.tIon, P.rtnershlp or Trust [Section 2-482 (c)]
. NAME OF CHIEF OFFICER, PARlNER, OR BENEFIaARY:
(()}J1IllJ fAJ. S/(/fJ(/,t
. IDENTIFY AlL PERSONS HOLDING, DIRECTlY OR INDIRECTlY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARlNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE L08BIED:
A) Full N....e of Indlvlclual/11tIe
B) Any Fln.ncilll, F.mHilIl or Profe....n.1 Rel.tionshlp
ie.
NONE.
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHElltER HOURL Y,
FLATRA7EOR OTHER):
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A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
Yes
or
1) Pursuant to Ordinance No. 2003-3393 Amendina Miami Beach atv 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":
yesS
Are O:OU.::::'ct on a=nt or.::,ndi~ bid f~ ~odsl eauioment or services. or on a Dresent
or oendina award for aoods. eauloment or semce?
2) Pursuant to Ordinance No. 2003-3395 Amendina Miami Beach atv 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 Lobbvists On Real Estate Develooment Issues":
Yes
V. SIGNATIJRE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHAll SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WEll AS COMPENSAnON
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE fILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSAnON DURING THE
REPORnNG PERIOD.
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Signature of Lobbyist
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 and all reporting
requirements.
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Signature of Lobbyist:
Signature of Principal/Client:
VI.
LOBBYIST IDENTIFICATION:
PRINCIPAL IDENTIFICATION:
o Produced ID
o Produced ID
Form of Identification
Form of Identification
~ Personally known (Lobbyist)
VD. SIGNATURE AND STAMP OF NOTARY:
o Personally known (Principal)
State of Rorida, County of Miami-Dade
Sworn and subscribed before me
This _day of . 20_
FOR LERK'S USE ONLY
Annual Registration fee: [ ] Yes [ ] No Amo nt id MCR # Date pa~'
Lobbyist Registration Form received and verified by: ~ (.~/ 0 <f
Revised 02110/04 F: CI:ER \MARIA-M\LOBBYIST\LOBBYIST FORM 04