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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 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
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 includes the
principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions" Please refer
to Ordinance 2004-3435.
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NAME OF LOBBYIST: st) (First) (M.!)
MTV NctWor~.=,LcmnArrlen~:~..1l11 L'rWn ~d)Mlomi r'Ynch,FL.3313?
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
'::l:>?- 12:'0 3o~ :J3'S-G.311 \CJr;~. ZCi u~n fF. LOrry
NUMBER: FAX N MBER: EMAI :
I. LOBBYIST RETAINED BY:
M W t-Jctworl( =:> .lcthn '.L\("('Y"n~ -=:In:::.
NAME OF PRINCIPAL/CUENT: I
MTV ~erworIL:J l.atTnArn:-nc:O:.::Ire) Illl.Llrca~ QaJrl M/(=,ml'Lroch. FL.33/37
BUSINESS NAME AND ADDRESS (Number and Stleet) (City) '(State) (Zip Code)
'.505 ) ':)~? - ~lOO ~.:>o:>~:>:> 'S -(~::>Il MT V LL\ LOm
T LEPHONE NUMBER: FAX UMBER: (Optional) EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
. NAME OF CHIEF OFFICER, PARTNER, OR BENEFIOARY:
~ccst- Me r::x-ldc
. IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
\! IClCo(1) .:I::/Y' .
II. SPECIFIC LOBBY ISSUE:
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Alloc:::.cmon"of- Eir-ontMonIC=:': MI~ml' Ococh V/~l"tDr ~
Issue to be lobbied (Describe in detail):
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III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
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CnnvcnT1cnAutht-,n+y lDun~ Advance-
mcnr f't;:jro(Y1.. -
A) Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
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C o nvcn-h on Auth ori tv 7v CA') "
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IV, DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
> . FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) tJ 0 (' ompcn~t(on' ,
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). ~o c.nm~n=-clh()(l
1) Pursuant to Ordinance No. 2003-3393 Amendinq Miami Beach City Code Chaoter 2. Artide VII. Division 5
Thereof Entitled "Campaign Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited
Campaign Contributions By Lobbyists On Procurement Issues":
Yes
2) Pursuant to Ordinance No. 2003-3395 Amendinq Miami Beach City Code Chaoter 2. Artide VII Division 5
thereof Entitled "Campaign Finance Reform". Via The Addition Of Code Section 2-490 Entitled "Prohibited
Campaiqn Contributions By Lobbyists On Real Estate Develooment Issues":
Yes
V. SIGNATURE UNDER OATH:
ON OCTOBER 15r OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, USTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES R COMP NATION DURING THE
REPORTING PERIOD.
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 contain in Se . n -482 of the Miami Beach City Code and all reporting
reqUirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI.
LOBBYIST IDENTIFICATION:
PRINCIPAL IDENTIFICATION:
Produced ID
Produced ID
Form of Identification
Form of Identification
Personally known (Lobbyist) I
Personally known (Principal) I
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This I ~ day of .:Jcpt- .20,.Q4
Si9S~~~~~~te of Florid;
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"'\~Vf~"", NtIA PREGO
l~m~~~NOtary PubHc . Stole 0' Florida
i' . jMiCol,.,1IiIIIIclf ,__,tug l1,ZD
;~ ~~ Commisllon # 00346272
"'''' Of! $'~
· ~....f.'. Ilond8cI Bv NaIonaI Notary Alan.
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This 12-day of 5cpr . 20-'2.4
S' n ture ~;u~ ~:: ~;~t1~ Flonda-- .. ---"
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f'J3m~t-\Notary Public. Stale 0' Florida
:' '~Ca,.,lissb,Elq:ns.Augll.ZD
\~~ ~/ Commission II 00346272
'1'1 OF f~ ,,'fi.
'.....". Bonded By NatIonal Notary Assn.
FOR CLER 's USE ONLY I I
Annual Registration fee: [/j Yes [ ] No Amount Paid O. (J (j MCR # 27 ;;J?J1o Date Paid q / ;;; I (cY;L
Lobbyist Registration Form received and verified by:
Revised 02/10/04 F: CLER\ALL\MARIA-M\LOBBYlS1\LOBBYlST FORM 04