Dona Zemo/Miami Beach Chamber of Commercem MIAMIBEACH
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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NAME OF LOBBYIST; (Last) (First)
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BUSINESS NAME AND ADDRESS
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TELEPHONE NUMBER;
(Number and Street) (City)
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FAX NUMBER:
(M.I)
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(State) (Zip Code) E
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EMAIL;
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPALJCLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zp 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, 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}~f~-Name of Individual/TiNe B) Any Financial, Familial or Professional Relationship
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N. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER
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A) LOBBYIST DISCLOSURE. (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION : R ~ ~
(equired).
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":
Y ~ o; Are ou lobb in ona resent or endin bid for oods a ui ment or services r
,o ona
present or pending award for goods, eguiament or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
Yes ~ ~ :Are ou lobb in ona endin a lication for a Develo ment A reement with the Ci or
a lication for chan a of zonin ma desi nation or chan a to the Ci '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 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..
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 EXPEi~D~TURES OR COMPENSATION DURING THE
REPORTING PERIOD.
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Signature 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 reportin
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requirements. . ___. , ~ :, ~~
Signature of Lobbyist: - ~ ~ `~ ~ ~l~
Signature of Principal/Client,
VI. LOBBYIST IDENTIFICATION;
PRINCIPAL IDENTIFICATION:
~ Produced ID
Form of Identification
b' Personal)
y known (Lobbyist)
D Produced ID
Form of Identification
Personally known (Princi al
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VII. SIGNATURE AND STA ,,,,~~r p~~,,,""
~' I.1111AN BEAUCHAMP 416 ULLIAN BEAUCHAMP
'',',Y ~~ ~~,,,~ *;` ~ MY COMMISSION # DD 530416
'~~~~~ ~"'• MY COMMISSION # DD 534
State of Florida, County of Miami-D a ~~ EXPIREg; April 29,~@e Hof rida, County of '~; o ,; ` EXPIRES: April 29, 2010
Sworn to and su {, :~~, . ~.• P~ ~ t.~, m~N~ P~~unae
bscnb before e, ,~r ,; ,~~~,, e«~am~,No~-~y subscn d befog . ' ry ~erB
This ~_day of is da
y of , 20_
.
Signature of Public Notary -State of lorida Signature f Public No ry -State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
FOR CLE 'S ONLY '
Annual R istration fee: ~ `~~
eg [ ]Yes [ ] No Amoun P ' r ~ MCR ate Paid
Lobbyist Registration Form received and verified by:
F:~CLER~$ALL~MARIA-M~Lobbyist~LOBBYIST fORM 05.doc Revised 12/08J04
V. SIGNATURE UNDER OATH: