Steven Tebon/S. TebonMIAMIBEACH
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, derision 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 prindpal 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) (M.I)
BUSINESS NAME AND ~DDRESS (Nummm~and Street) (City) (State) ' (Zip Code)
TELEPHONE NUMBER: FAX NUMBER]: EMAIL:
'r. LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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:
· IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTJERSHIP OR TRUST:
II. SPECIF'rC LOBBY ISSUE:
IssUe to be lobbied (Describe in detail): ' ~
III, CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Any Financial, Familial or Professional RelaUOlt.$hip ~q
C:) .¢-
A) LOBBYTST DISCLOSURE: (Required) I~J J J~
I
B) PRINCIPAL'S DISCLOSURE (OF LOBBYTST COMPENSA-I~ON): (Required).
DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURI
The following information must be answered:
Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
[] Yes ~/~ No: Are vou Iobbvincl on a present or pending bid for q0ods~ equipment or services~ or on a
/ present or oendina award for aoods, eauioment or service?
Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
[]Yes ~'.No: Are you Iobbyinq on a pending application for a Development Agreement with the City or
/
application for chanqe of zoninq map desiqnation or chanqe to the City's Future Land Use
Map?
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-orofit corooration or entity without soecial comoensation
/ ' or reimbursement..
V. SZGNATURE UNDER OATH:
ON OCTOBER IsT OF EACH YEAR, EACH LOBBYZST
STATEMENT UNDER OATH, LISTI'NG LOBE
RECEIVED, TN THE CITY OF MZAMI
SHALL BE FILED EVEN IF THERE HAVE BEE
REPORTING PERZOD.
CTrY CLERK A SIGNED
WELL AS COMPENSATION
NDAR YEAR. A STATEMENT
DURZNG THE
! do solemnly swear that all
familiar with the provisions
requirements.
Signature of LobbYist:
Signature of Principal/Cli, nt:
VI:. LOBBY]:~'I'
[] Produced ID
Form of Identification
2-482 of th~
Sic
~'i Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
of Lobbyist
)rrect and that ! have read or am
Beach City Code and all reporting
State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
Sworn to and subscribed before me Sworn and subscribed before me
This_day of'~;~ce~c~__~, 20~ This .day of ,20__ .
~- State ofytorida Signature o~-~'u-~ic Notary - S~t-~-~ Florida'
Notarization of Lobbyist's sign,,~ture No~rization of Principal's signature
Lobbyi~ Regi~ration For~eiv~-and~erified b~ ~ v - - / /
F:~CLER~$ALL~NA~A-N~Lobbyist~LOBBYI~ ~.do~/) Revi~d 12/08/~
Personally known (Principal)
PRTNCTPAL TDENTZFZCATZON:
Produced ID
Form of Identification