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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 III per50ns employed or retalned, whett1er paid or not, by a prIndpal who seeks to enCOU~ the paliMg., defeat
or modifialtlon of any ordinance, l1!50ll.Itlon, iI(;~on or dectslon of any eommlssioller; any action, deci$Ion, recommendation of the
City Manager or any city board or mmmlttee; or any action, ded$lon or l1!commendation of any city personnel defined in any
manner In this section, during the ~me period of the entire dl!dslon'maktng process on such action, dedslon or recommendation
that fllreseeably WIll be heard or reviewed by the city commi5$lon, or a dty board or committee. The term ~lIy includes the
prIndp;ll 85 well as any employee engaged i,., lobbying activitieS. The term "lobbyl.b" hIS .pedl'iI: tllduslons. PIe.1e I@fflr
to OtdlnllnlZ 1004-3435.
. ~fA
NAME OF L08llYlST: (iAtst) (First) (M.I)
.Al..~ t:JE\.. ~ l;t'O. l:::X::JY.) <:0\1 b~\ ti lAH\ ft- ?J~ \41 S0tre. '226
BUSIl\l'E$S NAMVNO ADDRESS (Number and Strett) (City) (State) (lip Code)
~~ /Qu'2:-c.ro::,~ ~L 2UI2-11a=>
TELEPHONE NUMBER: FAX NU'" ER: . EMAl~;
OfX1P
...
L LOIIIIYlST RETAINED BV:
~~ ()a. ~ \.:TO
NAME-'OF PRINCIPII1./CUENT:
b~ '6\'1
(I'l~mber and Street
~ ~5
-
EMAlL: (Optlonal)
fill a~t this scttlon If prindlNllls . (:orparlltiOn, partnanhlp or TI'\ISt [5ectlan 1-482 (en
. NAME OF CHIEF OFFICER. PAIl'TNER, OR BENEFICIARY: ~5\\U. ~'I l\" ~ll
O~~~.}..
. IDENTIFY AlL PERSONS HOlDING. DIRECT\. Y OR INOIRECTl Y. A 5% OA. MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
m. tITY AGENCES!JNOMDUALS TO III! LOB'IED:
A} Full Name or IndIVldu.l/ntla I) An, flnllnelal, Famllllll or Pro.....sion.' RallltlaMhlp
. .
c.rt'( of ~I ~ I ~ +b-
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Ll1 Y M1HMl I:lLH LLI:.I<K lJI:.l-' I
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1-'.115
N. DISCLOSURE Of Tt~MS AND AMOUNTS OF LOalYJ$'l' COMI'ENSA1ION (DISCLOSE WHmtER HOIJRL Y,
FLAtIl"~OR OTHER):
A) LOBBYl:STOISClOSUII.~=(bqull1ld) c;;"l~ ~ ~~.
EI) pIUNCIPAl'S DISCl.OSURE (OF L088VlST COMPENSAnoN): (R'\"'.rd). - c::> ~
VM ~m:u re_ntLna a nat-for-Drqfit CDrDCIratlon Dr entitv w~ut SDIlCi~" comlN!lISBtIDn or
~ _ ----!:- Pursuant to Ordlnal'lCle No. 2004-3435.
1) Pul'SUant to Ordinance ftI. 2003-3393 ~l!!ndin9 Miamlllaach CItv (".ode Chaotl!r 2. Amde VII Division 5
Thereof Entitled "ClImDilian Rnance Reformw V"18 The AdditiQn Of Code Section 2-488 Entitll!d ~Pl"Qhibited
Camoalon C".ootributions ~ Lobbvlsts On Procurement ls5ues":
VM C. ~1'8 voulDbbvina on a Dresem D~ ""ndlna bid far a- eauiament Dr servian or on a Dl'l!Sent
~ Dr IJIIl'ldl", award f9r goods. eauiom",t Dr _rvIll1!1?
. 2) Pursuant to Ot'dlnaMl! ND. 2003-3395 Amendlna Miami Beadl Citv Code OlaDter 2. A/tIde VII Division 5
,. ~;;;~~:~=;~,
@ :}_ _____~____~ . - = ~F~.:.....'
V. SlGNAlVRE UNDER OAT1f:
~N OCTOBER 15r Of EACH YEAR, EACH LOBBYIST SHALL SUBMIT 10 THE CITY ClERK A SIGNED
s:rATEMENT UNDO OATH, UmNG LOBBYING EXPENDITURES, AS WELL COMPENSAll0N
rueCElVED, IN THE aTY Of MIAMI BEACH FOR THE PRECEDING CALEN EAR. A STATEMENT
SHALL BE FILEt) EVEN IF THERE HAVE BEEN NO eXPENDITURES . .. NSAnore DURING THE
~PORnNG PERlOO. //
/"
,/
I do solemnly swear that all of the forego
familiar with the provisions contained i
requirements. .-
,
are true and correct and that I haVe read or <1m
Ion 2-482 of the Miami Beach City Code and all reporting
Signature of Lobbyist:
signature of Principal/aient:
VI. LOBBYIST JDIlNTIFlCA1ION:
PRtNCJPAL JDENTlFlCATtON!
Produced 10
Produced 10
Form of Identification
Fa.", of Identificatlol'l
Personally known (Lobbyist)
VII. SJGNAlURl! AND STAMP OF NoYARY:
State of Florida, County of Miami-Dade
~or~~bstrlbed--befQre me f
this day or ~ _ 202
1&_
Signature of Public Notiry - Stare of Florida
Notarization of Lobbyist's signature
o NafARYSEAL
IAN VERA
NOI'ARYPUBUC STATE OF FLORIDA
COMMISSION NO. DDOl3336
MY COMMISSIO EXP. MAR. 28 005
Personally known tprind!>>l)
Stllte of Aorlda, COunty' of Miaml.OiIde
Sworn and $Ub~re me
This ~daY of J ~:: f
Signature of PubliC Notary - State of Florida
NotarizatlDn of Prlndpars signatul'8
. ,
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/' FOR
~"ual Reglstra~on fee: ["1"Yes [ ] No Amount
(ollbylst Rellistmion Form received and verified bV:
Revised 02/10/04 F: elE
~~ ,,9 z;>. 0ate Paid 1 0/ cj-!(}y
IA.M\lOBBVIST\lOBBYlST FORM O~
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TOTAL P.05