Michael Andrews/South Beach Chamber Ensemble
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.
~dr!-tA) S ~~J
NAME OF LOBBYIST: (Last) (First)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State)
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TELEPHONE NUMBER: FAX NUMBER: EMAIl:
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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
FL
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAljCUENT:
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BUSINESS NAME AND ADDRESS
(Number and Street)
(City)
(State)
T
(M.I)
3 3/ SC1_
(Zip Code) .
@.IV\ jr'\6~ (7' inj .C()"1
(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
M~ OF~: ~;~ OR BENEAClARY:
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
.
.
II. SPECIFIC LOBBY ISSUE:
~ ItS ~1"r
Issue to be lobbied ( . in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A} Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
W1 RC-A-L-
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOIJRLY,
FLA T RA TE OR OTHER).
A) LOBBYIST DISCLOSURE: (Required) ~ D
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (ReqUired).~ D
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 lfNo: Are YOU lobbyinG on a Dresent or oendinG bid for Goods. eauiDment or services. or on a
Dresent or DendinG award for Goods. eauiDment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
~: Are you lobbyinG on a oendinG aDDlication for a Deyelooment AGreement with the City or
aDDlication for chanGe of zonina maD desianation or chanGe to the City's Future Land Use
MaD?
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..
jrYes D No: Are yOU representinQ a not-for-proflt corporation or entity without special compensation
T or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1 Sf OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDIllJRES, 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 EXPENDIllJ ES OR CO PENSATION DURING THE
REPORTING PERIOD. Or.i:
I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am
famil.iar with the provisions ~ontained 1\ S:~n 2-482 of the Miami Beach City Code and all reporting
reqUirements. ~
Signature of Lobbyist:
Signature of Principal/Client: '\
VI.
LOBBYIST IDENTIFICATION:
PRINCIPAL IDENTIFICATION:
~Produced ID ;.({ti b~ .pJ)3& s'1:??)~a-l 0
Form of Identification
l1Produced ID
.-~
.. ~..
Form of Identification
D Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
o Personally known (Princi
~'~~~'~""""oI! IJLIAM R. HATFIELD
~\ Notary PublIc - State of FIorldc
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....,;... Iclndect Iv NaIonaI Nokwy AIIn.
State of Florida, County of Miami-Dade
Sworn to a~ subscribed before me '1..-
This 0 - day of Trr:L-1/--h , 20D "f
~/{~/J (~ / :t:-I
Signature of Public Notary - State ofFlori a
Notarization of Lobbyist's signature
State of Florida, County of Mi
Sworn and subscribed befA me
This & PI. day of /htlAc. , 2ry:)7 .
Sig~~~~:'?;;Z~
Notarization of Principal's signature
->7 ~ FOR CLERK~S USE ONLY
Annual Registration fee: [ Yes [ ] No Amount Paid I;:f:- MCR #
Lobbyist Registration Form received and verified by: -~
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM OS.doc
Revised 12/08/04