John Safranek/Miami City Ballet 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, decision, recommendation of the
City Manager or any city board or committee; or any action, decision or recommendation of any city personnel 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
/n lobbying activities. The term 'Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
Safranek John L.
NAMEOFLOB~IST: (La~ (FIN) (M.I)
Miami City Ballet, Inc. 2200 Liberty Ave., Miami Beach, FL 33139
BUSINESS NAME AND ADDRESS (Number and S~eet) (City)
305-929-7000, e×t.1501 305-929-7002
(State) ' (Zip Code)
j ohn~miamicityballet, org
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
John L. Safranek/ Miami City Ballet, Inc.
NAME OF PRINCIPAL/CLIENT:
Miami City Ballet, Inc. 2200 Liberty Ave., Miami Beach, FL 33139
BUSINESS NAME AND ADDRESS (Number and Street) (City)
305-929-7000, ext. 1501 305-929-7002
(State) (Tip Code)
j ohn~miamicityballet, org
TELEPHONE NUMBER: FAX NUMBER: (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 BENEFICIARY: Pamela N. Gardiner
Executive Director
· IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INIEREST IN SUCH
CORPORA/ION, PARTNERSHIP OR/RUST: N/A
II. SPECIFIC LOBBY ISSUE:
Grant application to City of Miami Beach Cultural Affairs Program
Issue to be lobbied (De~ribe in detail): Tourism & Cultural Development (Cultural Anchors)
III. CITY AGENCZES/TNDZVZDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
Arts
Miami Beach Cultural
Council Members
DZSCLOSURE OF TERHS AND AHOUNTS OF LOBBYIST COHPENSATZON (DZSCLOSE WHETHER llOURL Y,
FI. A T RA TE OR 01HER~
A) LOBBYIST DISCLOSURE: (Required) 0
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required), 0
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
E] Yes ~1o: Are you Iobbvina on a oresent or oendina bid for aoods, eauioment or services, or on a
gresent or aendina award for aoods, eauioment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
I-1yes]~] No: Are you Iobbvina on a oendina aoDlicetion for a Develooment Aareement with the City or
aDmlication for chanae of zonina moo desionation or chanae ~o the City's Future Land Use
MaD?
3)
Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of
"lobbyist" as set forth in Section 2-481 above) who only appears as a representative of a not-for-profit
corporation or entity without special compensation or reimbursement for the appearance, whether direct, or
indirect, to express support of or opposition to any item, shall register with the clerk as required by this
section but, shall not be required to pay any registration fees..
~Yes [] No: Are you reoresentina a not-for-orotYc corooration or enUtv without soecial comaensation
or reimbursement..
V. SIGNATURE UNDER OATH:
ON OCTOBER Is'r OF EACH YEARv EACH LOBBYIST SHALL SUBM1T TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH~ L/STING LOBBYING EXPENDITURES~ AS WELL AS COMPENSATION
THE
RECE/VED~ IN THE CTI'Y OF MIAMI BEACH FOR PRECEDING CALENDAR YEAR. A/S'rA~EMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXP G THE
REPORTING PERIOD.
fa/~//~ Signature of Lobbyist
! do solemnly swear that all of the foregoin are true and correct and that ! have read or am
familiar with the provisions contained in/~j~cion 2-482 of the Mia~--~ch City Code and all reporting
V/. LOBBYIST IDENT[I~CA~ON: PR/NCIPAL IDENT~FLCA'r~ON:
[] Produced ID [] Produced ID
Form of IdenUfication Form of Identification
/l~ Personally known (Lobbyist)
VXI. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of MJami-Dade
Sworn to and subscribed before me
This (~-k~, .day of ,-1-~a~_ .20~
Signature o~b'i~c-Not~ry - State of Florida
Notarization of Lobbyist's signature
m
/,~Personally known (Principal)
State
of Flodda, County of Mia
Sworn and subscribed before
1~4't~day
This '
Signature of Public Notary -
Notarization of Principal's signature
Annual Registration fee: [ ] Yes [~] No
Lobbyist Registration Form received and verified by: ~..k~ ~ / -- /
F:\CLER\$ALL\MAPJA-M\Lobbyist\LOBBYIST fORM ~3'~c Revised 12/08/CH,