Affidavit (Walgreen Co.)
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CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
1700 Convention Ci'nter Drive
Miami Beach, FL 33139
cityclerktOlci.miami-beach.f1.us
AFFIDAVIT
LOBBYIST MEANS ALL PERSONS EMPLOYED OR RETAINED, WHETHER PAID OR NOT, BY A PRINOPAL WHO SEEKS
TO ENCOURAGE THE PASSAGE, DEFEAT OR MODIFICATION OF ANY ORDINANCE, RESOLUTION, ACTION OR
DEOSION OF ANY COMMISSIONER; ANY ACTION, DEOSION, RECOMMENDATION OF ANY CITY BOARD OR
COMMmEE; OR ANY ACTION, DECISION OR RECOMMENDATION OF ANY PERSONNEL DEANED IN ANY MANNER
IN THIS SECTION, DURING THE TIME PERIOD OF THE ENTIRE DEOSION-MAKING PROCESS ON SUCH ACTION,
DEOSION OR RECOMMENDATION THAT FORESEEABL Y WIL ~lE HEARD OR REVIEWED BY THE CITY COMMISSION,
OR A CITY BOARD OR COMMmEE. THE TERM SPECIFICALlI INCLUDES THE PRINOPAL AS WELL AS ANY AGENT,
ATTORNEY, OFFICER OR EMPLOYEE OF A PRINCIPAL, REG RDLESS OF WHETHER SUCH LOBBYING ACTIvmES
FALL WITHIN THE NORMAL SCOPE OF EMPLOYMENT OF SUCH AGENT, ATTORNEY, OFACER OR EMPLOYEE. EACH
PERSON WHO WITHDRAWS AS A LOBBYIST IS REQUIRED TO FILE A 'CERTIFICATE OF WITHDRAWAL."
1) Lobbyist Name: Bercow Jeffrey
Last Name First Name Middle Initial
Business Phone C31l.s) 177 - f; n 0
Message Phone L)
Business Address:
200 S. Biscayne Boulevard
No. Street
Florida
Miami
City
Email Address:
State
33131
Zip Code
850
Suite
2)
Principal Retained by:
Walgreen Company
If different from above
Deerfield
City
200 Wilmont Road
Street
Illinois
State
MS 2252
Suite
60015
Zip Code
(a) If a corporation, partnership, or trust, identify and provide the address for the chief
officer, partner, beneficiary or interests.
,.,0,'0-'-
3)
Subject Matter (Describe in Detail):
Design Review Board Approval
4. Identify each individual (Commissioners, Board, Committee, Authority member or City staff)
to be lobbied: Desiqn Review Board (wit , ,A./. " /..u..:..~) j {;.I, >Itjf'
S. The subject matter in number three (3) above is to be considered at the meeting of
(Identify each entity or individual):
on . 2000
on , 2000
on , 2000
on M..r",h ?n ,2000
on , 2000
on , 2000
o The City Commission
o City Commission Subcommittee
o City Staff
ex City Board or Committee Design Review Board
o Personnel
o Identify Others
6. State the extent of any business, financial, familial, professional or other relationship which
exists with any individual identified in number (4) above:
ON JULY 1sT OF EACH YEAR, EACH LOBBYST SHALL SUBMIT TO THE CITY CLERK A
SIGNED STATEMENT UNDER OATH, LISTING A LOBBYING EXPENDITURES IN THE
CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR.
Signature of Lobbyist:
)( Personally known
o Produced 10
Identify
o Did take an oath, or
J( Did not take an oath
State of Florida, County of Miami-Dade ""-
Sworn tj ~ sUbscribe~efore me ~
This day of 4~1001.
~wlo
Notary or Deputy Clerk
00.;;11';...... USA C. BROOKS
l~~.' ">.ff~ MY COMMISSION # CC 856829
i"; ,j,} EXPIRES: July 20, 2003
~~... .~;t- eond&dThIUNotarypWlk:Underwritflrs
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If Nf)tary, print, stamp or type as commissioned
FOR CLERK'" USE ONLY
Registration: ('fJ ACCEPTED ( J REJECTED DATE:
If rejected, state reason:
Registration fee paid: ( J Yes ( J ~( J Not-for-Profit Qrganizat!f t.{ Cj
( JCpsh f.- Check MCR# ?- S 0 -
DATA ENTRY DATE: ) tg 01 2000 ENTERED BY:
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