Joseph F. Blistein/Todd Brandon_ ~~i
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
Lobbyist means all per o divan Pe~ resolut onalactdion ortdeci pond of any ommP sionerl any action tdeci ionra ecommendation offthe
or modification of any
City Manager or any city board or Como estts on °uch action dells onl or ~ecommendation1that foreseeably wil~be heard or reviewed
period of the entire decision-making p
by the city commis s The term bLobbyists' has spec fic exclusions. IlPlease refer t r'Ordinancee2004-3435ployee engage
in lobbying activibe .. ~"'
NAME OF LOBBYIST:
BUSINESS NAME AND ADDRESS
~~_~
TELEPHONE NUMBER:
I, LOBBYIST RETAINED BY:
NAME OF
(Last)
(Number and Street)
S• G
FAX NUMBER:
'~ (M.I)
(First)
(City) (State) (Zip Code)
,i, .r • .
BUSINESS NAME AND ADDRESS
3o,f- X66 ~ ~G 2-
TELEPHONE NUMBER:
FAX NUMBER: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
~ ~y l
(St e) (Zp Code)
~A6t~~s@ ~ b~.~n~
EMAIL: (Optional)
(c)]
IDENTIFYTION PAROTNERSOHIPIORTROST: LY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORA ,
II. SPECIFIC LOB Y ISSUE:
~ `~
Issue to b to ied (De ribe in detail):
III, CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
(Number and Street) (City)
3or yuy -oy9 i
B) Any Financial, Familial or Professional Relationship
~l~
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHERr ,J~ ~
A) LOBBYIST DISCLOSURE: (Required) rJr ~ O~ ~ S
`~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). `y
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':
v _present or sending award for goods equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
a iication for change of zoning maD designation or change to the Citv's Future Land Use
Map?
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 CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITU OR COMPENSATION DURING THE
REPORTING PERIOD. - g
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:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
y~.~/12~pl111~@i~'*,,~+~e~g32 ~{B~yVtlzv
20`pRY PUBGi` Notary Public Star,; r;- ~.-n.,'!<t;; FO ~ Of Identification
Jilmca~Eva GroMl,r;
N9r, a`° Ex iF2s ~~~naily known (L byist)
EOF FAO P
SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
Thi day , 20 O~
Sign ture i -St of Florida
' a ion of Lobbyists signature
IDENTIFICATION:
~! Produced ID F~ ~ $1~f3 ~~/ 60 o2J' ~ v
Form of Identification
Personally known ( '
01pM1Y Poi Notary Public State of Florida
r ~ Jilma Eva Gronlier
' , ~ M Commission D0711401
N9~_'_~o- E Aires09l05l2011
State of Florida, Cour~i~'1~
Sworn and subscribed be ore me
This ~~ day,of~~W~+~r?a,, 20~~
Signature ~~tatgot-r~et'
Notarizatio of Principal's signature
FOR CLERK'S USA-ONLY L= ~ _~
Annual Registration fee: [ ]Yes [ ] No Amount Raid n-------y--~---- MCR # ~~ ~ '~ ~ Date Paid ~ ~ ~ C ~
Lobbyist Registration Form received and verified by: _ ' r- -~
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc Revised 12/08/04