Steven Marin/Enviro Waste Services Groupm 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. Thee term ~~Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
NAME OF LOBBYIST: (Last) (First) (M.I)
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BUS1NrSS NAME AiVD ADDRESS (Nurnber and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zp Code)
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TELEPHONE NUMBER: F 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 BENEFICIA Y:
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/INDIVIDUALS TO BE LOBBIED:
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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 HOURLY,
PLAT RATE OR OTHERS
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
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":
li~s ^ No Are you lobbvina on a present or pendina bid for goods eauipment or services, or on a
present or pendina award for aoods eauipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled °Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
^Yes ~1o Are you lobbvina on a pendina application for a Development Agreement with the Citv or
application for chanae of zoning map designation or chanae to the Citv's Future Land Use
Map?
3) Pursuant to Miami Beach City Code 2-484 (hl 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 CO_M,PENSATION DURING THE
REPORTING PERIOD. _.,....:;,,..-.-.°-.. __,_ ._.._,..~.--•---~
~'°"" - 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 reporting
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requirements. ~._ _..°-------
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
Produced ID
Form of Identification
--I"'ersonally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn o~P d subscribed before me
..Phis ~'~~'`~"~-day of `~:;v~l ~ IVETTE PINTO
~~.~ o~°"Y P e MY COMMISSION #DD510978
.~2, ~ FEB 11, 2010
Signature of Public Notary ~ ~0f oil r rough 1st State Insurance
Notarization of Lobbyi 's'"5f na~ur~~d
PRINCIPAL IDENTIFICATION:
Produced ID
Form of Identification
~rsonally known (Principal)
State of Florida, County of Miami-Dade
Sworn a subscribed b re ~_
This:...1' ay of ? ~~
( IVETTE PINTO
~ ~r°` ~ MY COMMISSION#DD510978
~~-~ - ~i_, ~ - i EXPIRES: FEB 11, 2010
Signature of Pubic otary - S Ems. fottldeled through 1st State Insurance
Notarization of Principal's
f FO ~ERK'S USF~ONLY .~ ~.
Annual Registration fee: [ " `] Yes [ ] No AmQ~u id `~ MCR # Date Paid V
Lobbyist Registration Form received and verified by: ` ~ "
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05 oc Revised 2/08/04