Kent Harrison RobbinsCity of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
Lobbyist means ail persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat
or modification of any ordinance, resolution, acton 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 aty 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 comniission,.or a dty board or committee. The terra spedflcaily Indudes the prindpai as well as any employee engaged
in lobbying activities. The term "Lobbyists" has~specific exclusions. Please refer to Ordinance 2004-3435.
~a~ 8 t n/S kG n~T ~-1 ~ ~R Aso os/
NAME OF LOBBYIST: (Last) (First) (M.I)
l~a2-~ ~~s~,I ~~i1C'7'"O n/ ~ v~; , ~1~9n~~ ~~~ f C. X33/3 9
BUSINESS NAME AND ADDRESS (Number and Street) (City) // . (State) II(Z''p Code)
~,~05 ~~. - QSC~D _5~3 / - ~ / SO ~n row i ~,«~7ri arrt ter-
TELEPHONE NUMBER:
~~~n6. C~3n.
I. LO~~B~~BYIST RETAINED BY:
~1T~. VP~ ~ul~ / !1
NAME OF PRINCIPAL/CLIENT:
BUSINESS NAME AND ADDRESS
3a5 -53~ --
TELEPHONE NUMBER:
55 ~~i/'1 ~- L~ ~,a~ ~ lit 3r3/.t¢/
(Number and Street] (pity) (State) (Zp Code)
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:
~.
L~
V
~' ~vtlo>om~.~ ~ o ~ 6`.5,2 .S ~ ~1 r,C~ ~a.~ ~
Issue to be lob d (Describe in detail):
III. CITY AGENCIES/INDI1lIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
u n/f'h ~- ~On
f ~ C~~
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHERf _
A) LOBBYIST DISCLOSURE: (Required) ~ 1 ?J~.
B) PRINCIPAC'S,DISCLOSURE (OF LOBBYIST GOMPENSATION): (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":
^ Yes [I~Tto: Are you iobbving on a present or pending bid for ooods, eauiument or services, or on a
present or Dendina award for ooods, eauiument or service?
,,
2) Pursuant to Miami Beach City Code 1x-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
Ma°?
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 compensatign 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 lpay any registration fees..
^ Yes ~'No: Are you representing anot-for-profit corooration or entity witho t special compensation '
or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1~ OF EACH YEAR, EACH LOBBYIST 51
STATEMENT UNDER OATH, LISTING LOBBYSN
RECEIVED, IN THE CITY OF MIAMI BEACH THE
SHALL BE F'~LED. EVEN IF THERE HAVE BEEN ' ii7(P
REPORTING fiERIOD. ' /
SUBMIT TO THE CITY CL K A SIGNED
LTURES, AS WELL ASPENSATION
THE
of
I do solemnly swear that of a oregc
familiar with the provision nt n in ~
requirements.
LL ,~ ~
$ ~ "' ignature of Lobbyist:
t
a
igna
ure of Princip
l/Client:
LOBBYIST IDENTIFICATION:
~' ^ Produced ID
z ~ Form of Identification
~~„~„N, ~i Personally known (Lobbyist)
SIGNATURE AND STAMP OF NOTARY:
fate of Florida, -County of Miami-Dade
om t nd bscrib . b me
This ay of , 200
/) r
sgnaeure or rutxrc
Notarization of Lobbyist's signature
true and c~ ~ and that I have read or am
F the Mi~~ffi E~!!~'I City Code and all reporting
J
PRINCIPAL IDENTIFICATION:
,
.
IN~N,N
^ Produced ID $
For of Identification $3
~Pe ally known (Principal]
8~~
State of FI r County of Miami-Dade ~
Sworn an ribed before me
D ~
This ~ N
V , 20~.,
Signature of is Notary -State of Florida
Notarizatio f Principal`s signature
Annual Registration fee: ]Yes [ ] No ~uR aLE SE ONMCR # ~ °~g I Date Paid ~ 3
Lobbyist Registration Form received and verified by:'
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc Revised 12/08/04