Jorge H. Quiroz/Fox Pan Americn
r,'Ji.ami SciIl;h
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
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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
in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
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FAX NUMBER: EMAIL:
NAME OF LOBBYIST:
(Last)
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(Zip Code) 33 otS
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BUSINESS NAME AND ADDRESS
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TELEPHONE NUMBER:
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAl/CUENT:
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BUSINESS NAME AND ADDRESS
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(Num er and Street) (City)
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FAX NUMBER: (Optional)
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TELEPHONE NUMBER:
II out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: <.J III/l1 e.s 6 t:1 f') l'i
· IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
SPECIFIC LOBBY ISSUE:
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ue to be lobbied (Describe in detail):
CITY AGENCIES/INDMDUALS TO BE LOBBIED:
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B) Any Financial, Familial or Professional Relationship I
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A) Full Name of Individual/Title
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLA T RA TE OR OTHER).
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A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). ?"
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":
DYes
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
DYes
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..
DYes
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR C PENSATION DURING THE
REPORTING PERIOD.
do solemnly swear that all of the foregoing facts are true and correct and that I have read or
miliar with the provisions contained in ion 2-482 of the Miami Beach City Code and all repo
quirements.
ignature of Lobbyist:
LOBBYIST IDENTIFI ON: ~ lJ.t,,# PR IPAL IDENTIFICATION:
rL Produced 10 b-t. - ~f- ~/-(};f}-O D Produced ID
., Form of Identification Form of Identification
o Personally known (LObbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
personally known (Principal)
Stat~ of Florida, County of Miami-Dade
Sworn ~ fPd subscrib b fore e
Thi$ ~day of 20f)5
Signature of Public Notary - tate
Notarization of Principal's sig
FOR
Annual Registration fee: [ es [ ] No Am u
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 0 .doc