HomeMy WebLinkAboutSuzanne Martinson/Oceanside ~..~i B~h
City of Miami Beach OMce of the City Clerk
1700 Convention Center Drive, Miami Beach, Ft_ 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, dedsion 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 spedfically includes the principal as well as any employee engaged
in lobbying activities. The term 'Lobbyists~,.~as specific exclusions. Please refer to Ordinance 2004-3435.
ar-h'n. n
NAME OF LOBBYIST: - (Last) (First) (M.I)
(State) (Zip Code)
B~I~INESS NAME AND ADDRESS (Number and Street) (City)
'~m~HONE~BER: FAX NI~IBER: ~' EMAIL:
LOBBYIST, RETAINED BY: . / ! ' '
I.
NAME OF PRINCIPAl/CLIENT:
- ~ ' -(~ib}) (Sta e) (Zip Code)
B~JSINESS NAME AND ADDRESS (Numar and Steer)
~LEPH~NUMBER: ~ - F~ NUMBER: (Optional) EMIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
· NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
· IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
~T~GJ~{II. SPECIF/C,,~BBY ISSUE:
]'ssue to t~bbied (Describe in detail): i
III. ~ AGENCIES/INDIViDUALS TO BE LOBBIED:
A) Full Nai~llUe,
B) Any Financial, Familial or Professional Relationship
IV. DZSCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DTSCL~¥HETHER HOUR£ Y~
^,%,;,; ,o; ,; .o%%., ..,,,, ..,, *1'7 I h
The following informa~on mu~ ~ answered: ~~~
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
Yes .~,No: Are you Iobbvina on a or~-_nt or oendina bid for ~o_nd~, eoui~ment or services, or on a
i)~_nt or =endin= award for ooods, e=uiDment or service?
2) Plrsuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real
2te . . .
Development
Issues":
BYes~;o: Are vou Iobbvin. on a ~endin. ,Dolication for a DeveloDment A~lree_m..e.,n.t wi.th the C, .t~. or
/ ~ application for chanae of zonina mad de_~!ap.a_h.'on or chanue to the City s Fugure ~ana u~
3) Pursuant to Miami Beach City Code 2-48~ (h) Any person (except those exempt from the definition of
"lobbyist" as set forth in Section 2-451 above) who only appear~ 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 suppor~ 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..
D Yes y~l~ o: Are vou repr=~-ntinQ a not-for-profit corporation or entity without special compensation
or reimbursement..
V. SIGNATURE UNDER OATH:
ON OCTOBER 1;r OF EACH YEAR, EACH LOBBYIST SHALL SUBHIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COIqPENSAT[ON
RECEI~/ED, IN THE CITY OF HIAIqI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE
,J7 .... ,/Signature of Lobbyist
! do solemnly swear that all of the foregoing fara~ are t~e and correct and that ! have read or am
familiar with the provisions contained in Section 2-q82 of the Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist:
Signature of Pri ncipal/Clie~.' (~~ .~--,'~~ J//J,~(~'
Form of Identification Form of Identifi ation OFFICIAL NOT^R¥SEAL
LILLIAN BEAUCHAMP
[] Personally known (Lobbyist) [] Personally known (Principal) NOTARY PUBLIC STATE OF FLORIDA
COMMISSION NO. DDI09289
VII. SIGNATORE AND STAMP OF NOTARY: MYCOMMISSION
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This ~? day of ,~-~1~_ . 20__~
v S~nat-ure ~Pub~: Notary -State of Flofi~
Notarization of Lobbyist's signature
State of Florida, County of Miami-Dade
Sworn and subscribed before me ~
This ~/ day of~~J~
FOR CLERK'S_US_E~NLY ~-~ ~,~,
Annual Registration fee: [/'~.Yes [ ] No ~ount ~aid ~~ ~CR ~ ~~
Lobbyist Regis~tion Fo~ received and vedfied by: ~. ~
F:~CLER~$ALL~MAR~-M~Lobbyi~LOBBYI~ ~RM 05~
Date Paid ~:)/-~--I/(::~-
Revised 12/08/0~