David Kelsey/So. Beach Hotel & Restaurant Associationm 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 "`Lobbyis~" has specific exclusions. lease refer tjQ` Ordinance 2004-3435.
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BUSINESS NA E AND ADDRESS (Number and Street) (City) _ State) ~ (Zp Code)
FAX NUMBER: (Optional) EMAIL:
Fill out this section if pnncipal ~s a Corporation, Partnership or Trust [Section 2-482 (c)]
• NAME OF CHIEF F OFFICER, PARTNER, OR BENEFICIARY: ~~~ ~ ~ ,~~~~ ~C n ~ S
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• 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:
A) Full Name of Individual/Tithe B) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
PLAT RATE OR OTHERJ: ~q~ ~I
A) LOBBYIST DISCLOSURE: (Required) _ f [~1 '[ 1~'~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
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":
^ Yes ~llNO: Are you lobbying on a present or pending bid for goods eauioment or services or on a
present or oend~ng award for ooods eauioment or service
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
^Yes l~ No: Are you lobbvino on a nendina aoulication for a Development Agreement with the Ciri or
apphcat~on for change of zoning man designation or change to the City's Future Land Use
Mao?
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
t section but, shall not be required to pay any registration fees..
~lYes ^ No: Are you representing anot-for-profit corporation or entity without special comuensation
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 EXPENDIT t ES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECED CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITUR 5,. R C MP ATION DURING THE
REPORTING PERIOD.
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I do solemnly swear that f the foregoing facts are true and correct and that I have read or am
familiar with the provisions on fined in Section 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 ~ Produced ID
Form of Identification Form of Identification
personally known (Lobbyist) ^ ker~Onally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscri ~~
This ~~! ~y of ~~~ ~ "'••. 2 HERNANDEZ
_ :+_ SAY COM ISSION # DD 626373
~ ~'•. ' ` EXPIRES: May 3, 2011
.. ~P:
Si natur biiE • ." ublicUMerx~fters
Notariz , ion of Lobbyist's signature
State of Florida, County of Miami-Dade
Sworn and subscribed b e me
This ~~'tiay of - ~RyHERN~w gN~DQ
MY COMMISSION # DD 626373
Signature of Publ' to . ~'•~ ' "'6i~ NaaryPubu~u„d„w,~,e
Notarization of Princijial'~--' ~
FO C 'S S ONLY , ~\ <c1 ~ 7 ~~
Annual Registration fee: [ ]Yes [ o Amo t i MCR #a~ ate Paid J
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc Revised 12/08/04