Atlantic Broadband 12/08/05 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 l~he passage, defeat
or modification of any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the
Oty Manager or any city board or committee; or any action, decision or recommendation of any' db/ personnel defined in any
manner in this section, during the time pedod 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 db/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,
NAME OF LOBBYIS~T: (Last)
BUSINESS NAME AND ADDRESS (Number and Street)
(First) (M.I)
(City) (State) (Zip Code)
TELEPHONE NUHBER:
FAX NUMBER:
EMA[L:
I.- ' LOBBYIST RETAINED BY:
NAME, OF PRINCIPAL/CLIENT:
BUSINESS NAME AND ADDRESS' (Nu--mber and Street). (City) '
'TELEPHONE NUMBER: FAX NUMBER: (Optional)
(state)
(Zip Code)
EMAIL: (OpUonal)
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:
II, SPECIFIC LOBBY ISSUE:
'issue to be lobbied (Describe in detail):
III. CTI'Y AGENCIES/INDIVIDUALS TO BE LOBBIED:
'B) Any Financial, Famm)m,a
? I or I~Smeni~[l~l~itr6n~l),ip
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER lYOURI. Y~
F1.AT RATE OR OTHER.):.
A) LOBBYIST DISCLOSURE: (Required) ~t~"[.
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required)._ .~b ~.'~;~. C._~_~ c,~ h~~
~a not-for-nrofit ~'ornoration or enti'-- witho ......... I -'reimbursement.
· ut5 ecml corn en atJon or
Pursuant to Ordinance No. 2004-343S.
1) Pursuant to Ordinance No. 2003-3393 Amendin Miami Beach Ci Code Chater 2 Article VII Division 5
Thereof Entitled "Cam ai n Finance Reform" Via The Addition f Code Section 2-488 Entitled "Prohibite
Cam ai n Contributions B Lobb ists On Procurement Issues":
·
Yes o: Are ou Iobb in on a r senior oendinn bid for-oods "-ui-ment or -~,ervices or on a
or ndl ward for ods ui rnent or servi e? res n
2) Pursuant to Ordinance No. 2003-3395 Amendin Miami Beach Ci code Cha ter 2 Article VII Division 5
ther " · · , · ,,
eof Entitled Cam al n Finance Reform Via The Addition Of Code Section 2-490 Entitled Prohibited
. . Cam ai n Contributions B Lobb ists On Real Estate Develo ment Issues": ernest with the Ci- or
V. SIGNATURE UNDER OATH:
ON OCTOBER Is'r OF EACH YEAR, EACH LOBBYIST SHALL SUBMTr TO THE CTTY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDTrURES, 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 EXPENDTrURES ~ COMPENSATION DURING THE
REPORTING PER[OD. .
Signature of Lobbyist
I do solemnly swear that all of the foregoing facts are true and correct and that ! have read or am
familiar with the provisions contained in Section 2-q82 of the Miami Beach City Code and ail reporting
requirements.
Signature of Lobbyist: _ . ..... ·
SignatureofPrincipal/Client~."_~~~''~ VI ~.. ~ ~'~'~ I~::t~_w,J~I
VI. LOBBYIST IDENTIFICATION:
VII.
[] Produced ID
Form of Identification
~Personally known (Lobbyist)
SIGNATURE AND STAMP OF NOTARY:
PRINCIPAL IDEN IFIC
[] Produced ID
Form of Identification
~ersonally known (Principal)
State' of Florida, County of Miami-Dade
Sworn ~to and subscribed before me ',
This_ "7 _day of ~__~-
Signature of Public Notary - State of Florida
N ~'~U-g [-g --g-~{~ ~a t u re
' '~',.m~ Florida Notary Assn., lnc _-
~lllllllll Illll I Illll l II Illll'il I Il I el · · e~lillll
State of Florida, County of Miami-Dade
Sworn and subscr/bed 'before me
This _~___day of~[~..~, 2~
Signature of Public Notary - State of Florida
Nota~r,i,z,,a,,t~,,o,n,. of Principal's signature
r LAURA CAMO . =
FOR CLERK'S USE ONLY ·
Annual Registration fee:.. [ V"~] Yes [ ] NO Amount Pai~ MCR #
Lobbyist Registra~on Form received and verified by~ ~, _ -
Revised 02/10/04 ~ER~ALL~HA~A-H~LOBBY~S~LOBBY~ FORH 04