Jaie Laplante/Florida Iinternational Universitym 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, deasion 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 LOBBY{ST: (Last) (First) (M.I)
FIOr+C~~a 1(~t~Y~~'I,Cr~ctl UnIYCf,>~~
C1o SWS , 1l~0o NW 11~3r-d S}~ M+ar-n+ FL. 33119
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
3075-CDa'1-15QU,i 305-(~a~l--~+-~C~~ ~Crplcan~e.. ~ ~tU.~l.1
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
ti Ict-~cia ~r,-Eer-r,ca~iar~cil l..ln~yee-s+~
NAME OF PRINCIPAL/CLIENT:
rlori~ta 1n~ena-honcll L1n+ve,I'Si~
,..-. 11200 SW 8+h si-r-~~1'j Phrarrn~r_I ~rer,a RM mil; 5 M iGm- FL 33i ~lq
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zp Code)
30~ - 3:~-~ - 23q g
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:
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II. SPECIFIC LOBBY ISSUE:
Issue to be
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
M'+am+ ecxyi-. V~ 5-~-- c~r1
Cc~vcn-1,on i~rthor+-4y
1~I ~p~ .
,IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHERS .., -
A) LOBBYIST DISCLOSURE: (Required) ~ ~ ~~~~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
~~'~.16
3 ,Soo
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~`19No: Are you lobbying on a present or Wending bid for goods, eauioment or services, or on a
oresent or_ Qendina award for goods, eauioment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
application for change of zoning man designation or chance to the City'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 snot-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 CALE AR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR PENSATION DURING THE
REPORTING PERIOD. /J ~ Cl/ / /
I do solemnly swear that all of the foregoing fiefs are true and correct and that I have read or am
familiar with the provisions contained in Se o 2-482 of the Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist:
Signature of Principal/ nt:
VI. LOBBYIST IDECNTIFICA O, IN: PRINCIPAL IDENTIFICATION`:t
Produced ID I ~~~ ~-~YS ~~~ 70 Cam' O `Produced ID ~L~~~~ Y~70~~
Form of Identification Form of Identification
^ Personally known (Lobbyist) ^ Personally known (Principal)
7 LILLIAN B
VII. SIGNATURE AND ST F NOTARY: { °~• • CO F.AUCHAMP
~ ,~ +~ MY MMISSION 4' DD
'''--"'-' !! ~; 530416
~~'~` "y~, LIWAN BEAUC . t ••.,. ~~: EXPIRES: April 29, 2010
State of Florida, County of Mia -,[~~ . ~.* HAMPSta e f Florida, County of Miami- ~~ e~anH,,,N,,,,y,~
Sworn to ar~d subscribe befor `~ r~' ~- MYCOMMI5510N~pp~q~or and subscribed before me
This ~`~"~ day of ~dQN ~ ~ '+~" gora~drpneB,N~'~p~„y~~Ihis day of ~l,/PH6~ , 20 ~ 7
~,~~
~ nature of Pu is Nota -State f Flor' a Si natu~Pub c N t -State of Flo idac N t -State of Flo ida
9 rY 9 rY
Notarization of Lobbyist's signatur _. Notarization of Principal'sy,signature
FOR ER ' ONLY
Annual Registration fee: [ ]Yes [ ] No Amount id MCR # ate Paid
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.d Revi d 2/08/04