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MIAMI BEACH
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, 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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N LOBBYIST:~) (First) - 1 ~
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BU INESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER:
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(M.I)
FAX NUMBER:
EMAIL:
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I. LOBBYIST RETAINED BY:
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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)l
. 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:
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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 Relationship
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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).
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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":
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 compensatio ur t for the appearance, whether direct, or
indirect, to express support of or oppos' . 0 any item, shall regi er with the clerk as required by this
section but, shall not be required t y any registration fees..
~es D No: Are ou re rese .
/~ or reimburs ent.
ON OCTOBER 1ST OF E
STATEMENT UNDER OATH, LISTING LO YING EXPENDIT
RECEIVED, IN THE CITY OF MIAMI BEA H FOR THE PR DING CALENDA
SHALL BE FILED EVEN IF THERE HAVE EEN NO EXP DITURES OR
REPORTING PERIOD.
Signature of Lobbyist:
Signature of Principal/Client:
V.
VI.
LOBBYIST IDENTIFICATION:
PRINCIPAL IDENTIFICATION:
D Produced ID
D Produced ID
Form of Identification
@ersonallY known (Lobbyist)
VII. SIGNATURE AND STAMP OF N
Form of Identification
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.", OF F,tfiT
D Personally known (Principal)
Notary F'ublic: St!te of Florida
Geishel Valverde
My Commission OD576135
Ex ire~tJM:M<tityrida, C
This _day of
nty of Miami-Dade
ed before me
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Signature of Public Notary - State of Florida
Notarization of Principal's signature
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Date Paid
Revised 12/08/04