Edward Holleran/Atlantic BroadbMIA M I B EAC H
City of IVliami Beach Office of the City Clerk
:[700 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
in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
NAME OF LOBBYIST: (Last) (First)
BUSII~ESS NAME AND ADDRESS (Number and Street) (City) f
TELEPHONE NUMBER: FAX NUMBER:
~(M.I)
(State) ~ / (Zip Code)
EMAIL:
I. LOBBYIST RETAINED BY:
NA~E 6F' PRINCIPAL/CLIENT:'
'~SINESS NAME AND ADDRESS (Numbe~ a~d ~eet) (Ci~) / ' - - '(State~ ' (~p C~e)
TELEPHONE NUMBER: F~ NUMBER: (Opaonal) EMAIL: (Optional)
Fill out this section if principal is a CorporaUon, 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 Jn detail):
XIX. CXTY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
]V. D:[SCLOSURE OF TERMS AND AMOUNTS OF LOBBYI'ST COMPENSATZON (DXSCLOSE WHETHER HOUR/
FLA T RA TE OR 077'1£R~
A) LOBBYIST DISCLOSURE: (Required) ~_.~.'~'~'~'~-~~ -~~~~:~ /~ ~'
B) PRZNCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). t~l~)~ ,i~j~ /~_~~
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":
_~es E] NO: Are you Iobbyin,q on a present or pendinq bid for qoods, eQuiument or services, or on a
present or pendinq award for qoods, eQuioment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
~o: Are you Iobb¥inq on a pendine application for a Development Aqreement with the City
[]Yes
apolication for chanqe of zoninq map des_!qnation or chan,qe to the City's Future Land
Hap?
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 ~:~o: Are you representinq a not-for-profit corporation or entity without special compensa~;on
or reimbursement..
V. SZGNATURE UNDER OATH:
ON OCTOBER Is"r OF EACH YEAR, EACH LOBBY[ST SHALL SUBMTT TO THE CiTY CLERK A STGNED
STATEHENT UNDER OATH, LTSTTNG LOBBYTNG EXPENDZTURES, AS WELL AS COMPENSATTON
RECEZVED, TN THE CZTY OF MTAMT BEACH FOR THE PRECEDTNG CALENDAR YEAR. A STATEMENT
SHALL BE F/LED EVEN TF THERE HAVE BEEN NO EXPENDZTURES OR COMPENSAT/ON DUR]:NG THE
REPORTZNG PERZOD. ~
Signature of Lobbyist ~'
! 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 2-482 of the Miami Beach City Code and all reporting
Signature of Lobbyist: _
Signature of Principal/Client: ~ ~ .~// ~ ........
VL' LOBBYZST ]:DENTI:FZCATZON: qL~ PR:ZNCTPAL zDENTzFZCA'I'ZON:
Form of Identification Form of Identification
[] Personally known (Lobbyist)
STGNATURE AND STAMP OF NOTARY:
[] Personally known (Principal)
· State of Florida, County of Miami-Dade
Sworn, Jko, and subscribed I;Ip, f~m.me.. ......... '-':'::'-'"'"'"'"'q,
Signature of Public Notary ~ ~,~ Fl~FiOilUa No~a~/~n.. ~,,~
Notanzabon' ' of L obb.,o. ~'~i~~t~"""'" o s~jnazure ....
State of Florida, Co~.~.$t(.~j~]]i;~W;~, ....... ........ ....
Sworn,.~d. su bscri~or
~is ~a~of ~%, 2~~ ~- :
- ('Z'~. ~
Signature of Public
No~rization of Principal's signature
'" FOI~ ,!~ U,,~ ONLY
Annual Registration fee: [ L~ ] Norfto_~t Paj~ ~' MCR #
Lobbyist Registration Form received and verified
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM
,Date Paid