Alison C. Burgos/Aqua Foundation for Womenm 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 modifiption 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, derision or recommendation of any dty 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 tt-e city commission, or a city board or committee. The term specifically inriudes the principal as well as any employee engaged
in lobbying activities. The7t~erm "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
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NAME OF LOBBYIST: (Last) (First) (M.I)
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BUSINESS NAM AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
L LOBBYIST RETAINED BY:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (.Tip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
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 lobbied (Describe in detail):
III. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/T'itle B) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER]
A) LOBBYIST DISCLOSURE: (Required) ~_~
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":
II_1Les ~`No: Are you lobbv'na on a present or oendina bid for goods a uioment or services or on a
present or pending award for goods eawpment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
CYes ~CNo: Are you lobbvina on a pending application for a Development Agreement with the City or
aiaphcat~on for change of zomna map des~anation or change to the Citv's Future Land Use
Mau?
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..
t~Yes ^ No: Are you representing anot-for-profit cor oration or entity without s ial compensation
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.
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
requirements. .
Signature of Lobbyist: L~~r.~ ~^^-
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID u~~I- ~ (022-- 3--b~--~]~~~ duced ID ~L ~fo2Z'Or~ -f;~? 9~6,"O
Form of Identification Form of Identification aka
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP
State of Florida, County of Miami-Dade
Sworn to and subscribed before o G
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This ~D~ day of ~, 200- ~
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Signature of Pu lic Notary -State of FI rJ'da
Notarization of Lobb
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State of Florida, County of Miami-Dade `cfAo'~~ d
Sworn and subscrib before me ~9`~sss%~
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dig u e Public Notary -State of Florid
(~o ation of Principal's sienat~~ra
/ FOR CLERK' E ONLY ~ r
Annual Registration fee: [ ]Yes [ ] No Amo ti id . MCR # Date Paid f
Lobbyist Registration Form received and verified by:
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