Heraut Vixamar / Union Security
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, Fl33139
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, resoiution, 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 defmed 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: V (Last) (First) yrf~. . (M.I)
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(Number and treet) (City) (State) (Zip Code)
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FAX NUMBER: ~ EMAIL:
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAl/CLIENT:
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BUSINESS NAME AND AD~ESS )NUmbe.!: and Street) (City)
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TELE HONE NUMBER: FAX NUMBER: (Optional)
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(State)
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(Zip Code)
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Fill out this section if principal Is a Corporation, Partnership or Trust [Section 2-482 (c)l
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
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IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A S% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION. PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
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ssue to be lobbied (Describe in det i .
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III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Indlvldual/lltle
B) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLAT RATE OR OTHER):
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A) LOBBYIST DISCLOSURE: (Required)
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
nsation or
1) Pursuant to Ordinance No. 2003-3393 AmendinQ Miami Beach Citv Code Chaoter 2. Article VII. Division 5
Thereof Entitled "Camoaian Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited
CampaiQn Contributions Bv Lobbyists On Procurement Issues";
GNO:
Are vou lobbying on a Dresent or DendinG bid for Goods. eauiDment or services. or on a Dresent
or oending award for aoods. eauiDment or service?
2) Pursuant to Ordinance No. 2003-3395 AmendinQ Miami Beach Citv Code Chaoter 2. Article VII Division 5
thmof Entitled "Camoaign_Finance Reform". Via The Addition Of Code Section 2-490 Entitled "Prohibited
Camoaian Contributions Bv Lobbvists On Real Estate Develooment Issues":
V. SIGNATURE UNDER OATH:
ON OCTOBER 1 Sf 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 CIlY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURE 0 COMPENSATION 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 contained in Secti n 2-482 of the Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID FL/a:1/. II .zrid20 '6Z'(frJOProduced ID FI V.:2S(o -, '1':X:> ~ 0;;l-/J-tr-o
IForm otIdentification Form of Identification
Personally known (Lobbyist)
Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworr~ 6ubscrjCi: before me ~ /
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Signature of Public Notary - State of Florida
Notarization of Principal's signature
~. FOR CLERK'S
Annual Registration fee: [ ] Yes [ ] No Amount Paid /
Lobbyist Registration Form received and verified by:
Revised 02/10/04 F: CLER\ALL\MAR
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BBYIST\LOBBYIST FORM 04