Grace Calvani/Miami Beach Latin Chamber of Commercem MIAMIBEACH
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139 ~ p
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LOBBYIST REGISTRATION FORM ~ L- ~
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Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the ~assagetitiefe~
or modification of any ordinance, resolution, action or decision of any commissioner; any action, decision, recomme~dati6ri~of tHe'' 1t
City Manager or any city board or committee; or any action, decision or recommendation of any city personnel duFing timer.
period of the entire decision-making process on such action, decision or recommendation that foreseeably will be hei3YG or rriewe3`~
by the city commission, or a city board or committee. The term specifically includes the principal as well as any em~yee~rgagao'~1
in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.-T, ..
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NAME OF
(Last)
~i .
(M.I)
-tip n~.~.r~~aa ~ivunwer anu J~ree[I tury~ (State (Zip Code)
(~,,30~> (e~ y- - 1 ~6 `f ~ 3a~) ~~ ~' `10.S' ~- vvtb L cc E ~eids o ~d~.. he M-
TEL HONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
1n. _.. `~
e ~ .si.,
NAME OF PRINCIPAUCLIENT:
~t~ Lr~rtCOl n ~oa~. ~i. ~ ~~ ~ 3~
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zp Code)
~~ ~~~ - c~~~ (305 J~e~~f~ ~~2.
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section if pnnc~pal ~s 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. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
n~~~prce~
A) Full Name of Individual/Tithe B) Any Financial, Familial or Professional Relationship
C~ r ~ ~m~ r~ -~1or~ ~..
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER]
/ ~ / --~
A) LOBBYIST DISCLOSURE: (Required) lCJ1~~CP~ ( _ ~ [~~a~ I' pp ~~G/--
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).~~~ (1 L1Ll r'1 y~/!~~'
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
C-{i Procurement Issues":
present or oendina award for goods equipment or service
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
application for chance of zoning mao designation or chance to the Citv'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 anot-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..
or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1~ OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, 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 EXPENDITURES OR COMPENSATION DURING THE
REPORTING PERIOD. ~. !~:
Signatur~ of Lobbyist
I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am
familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
9~ Produced ID ~"L • ~ ri uQ 1'~ ~.~Ei ~C.,
Form of Identification
PRINC AL IDE/N~TIFICATION:
Form of Identification
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
~] Personally known (Principal)
State of Florida, County of Miami-Dade State of Florida, Cou
Sworn to arsd subscribed bef re me 1 ~ Sworn and subscrib ~ ~~t;~.Cne I~RRYHERNANDEZ
This ~i day 20 This 3 day of w :+- 2~Y~O~fiSSION # DD 626373
••»r •,,, °""~ „~d' E PIRES: May 3, 2011
?'~ .: KERRY HERNgNDEZ bonded Thru Notary PubNc Undenvrlters
Si nat re of li o - ~ I #D0626373 Signature of P a -State on
Notarizat' n of Lob ` ~ "~~ ` I~t~N ~~Y3'2011
otaryWbNc~ Notarizati of Principa s
- FOR CLERK'S SE ONLY ~/~
Annual Registration fee: [ ~j'Yes [ ] No Amount Pai MCR # l./ Date Paid 7 j O
Lobbyist Registration Form received and verified by: ~ ,
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.do Revised 12/08/04