Goodman, Joel / Clio Awards
Nov-05-2004 03:49pm From-CLIO AWARDS
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T-434 P,OOl/002 F-653
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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 prfndpal 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 dedsion-maklng process on such action, decision or recommendation
that foreseeably will be heard or reviewed by the city commissJon, 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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(Last)
(First)
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(City)
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FAX NUMBER:
(M.I)
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(State) (ZIp Code)
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EMAIL:
NAME OF LOBBYIST:
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BUSINESS NAME AND ADDRESS
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TELEPHONE NUMBER:
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(Number and Street)
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAl/CLIENT:
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TELEPHONE NUMBER:
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FAX NUMBER: (Optional)
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(State) (Zip Code)
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EMAIL: (Optional)
Fill out this section" principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
NAME OF CHIEF OFFICER, PARTNER, OR BENEFIaARY:
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (DescrIbe In detail):
IU. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Any Financial, Fammal or Professional Relationship
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Nov-05-2004 03:49pm From-CLIO AWARDS T-434 P.002/002 F-653
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLA T RA TE OR OTHER):
A) LOBBYISTDISCLOSURE:(ReqUired)5a....(W1-ci_-f~(~e..6L.-/~((o f}w~- {L.tJ !--r/<hrrun..-,.J C~7J--5.;;tJ'C;...
B) PRINOPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): '(Requlred).S.JLviJ C l{IJ ~ '''l~ - 1.l.1) c"tJ{1id't~ ~M
Yes N: t
1) Pursuant to Ordinance No. 2003-3]9] Amendina MIami Beach City Code Chapter 2. Artlde VII. Division 5
Thereof Entitled \'Campaj(~n Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited
Campaign Contributions By lobbyists On Procurement Issues";
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2) Pursuant to Ordinance No. 2003-3395 Amendina Miami Beach City Code Chapter 2. Article VII Division 5
thereof Entitled "CampaJan Finance Reform", Via The Addition Of Code Section 2-490 Entitled "Prohibited
Campaign Contributions BY Lobbyists On Real Estate Development Issues":
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST ALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING ENDITURES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR E RECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO E PE
REPORTING PERIOD. \
I do solemnly swear that all of the foregoing facts are ue and correct and that I have read or am
familiar with the provisions co fned In Section 2-482 of the Miami Beach City Code and all reporting
requirements. A
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Signature of LObbyist: t
Signature of Principal/Client:
PRINCIPAL JDENnFICAnON:
VI.
Produced ID
Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
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State of RefIea, COunty of HlaR:li-l"'\~
Sworn to and subscrib before me
This % t1- day of 200
Signature of P IW1Jotj
Notarizatlo of Lo byist's signature
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Notar}' PU);:C, S!ii'l2 of I!inoi~
My COlili11iss:on [),p~E:'~; r,~~,~v ?5, 20C8 ';,
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Signature of Public Notary - State of Florida
Notarization of Principal's signature
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Annual Registration fee: [ Yes [ ] No Amo Paid , MC~Date Paid J tJ I!:J {) f
Lobbyist Registration Fonn received and verified by' I /
Revised 02/10/04 : CLER\ALL\MARIA-M\LOBBYIS1\LOBBYIST FORM 04