Raymond Sullivan/Miami Contemporary Dance Co.~+ 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 enwurage 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, decision 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 refe~ to Ordinance 2004-3435.
n ~1. _ ~
NAME OF LOBBYIST:
1~I~aM- Co~~n,~~.,,
i NAME A/ID ADDRESS
6.. O
NE NUMBER:
per and Street)
.? $3~ c
FAX NUMBER:
(First) // (M.I) ?
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. M,ar-~ eu~,~i.__
(State)
IQlrll C~~
EMAIL:
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BUSINESS NAME AND ADDRESS (Number and Stre ) (City) (State (Zp Code)
6- G33 ;S~ -a m, a~
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: i al)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~ ~ , [~l, ~J~
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A S% OR MORE OWNERSHIP INTEREST IN SUCH /~ i
CORPORATION, PARTNERSHIP OR TRUST: ~ ~/
II. SPECIFIC LOBBY ISSUE:
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
i i J J ~I
1 ~ ~ 1 Mme ont^
'~ ~a
I. LOBBYIST RETAINED BY:
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":
^ Yes OSl N0' Are you lobbying on a oresent or oendina bid for goods eguinment or services or on a
present or oending award for goods eguioment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
^Yes EO NO' Are you lobbvina on a oendina aoolication for a Develooment Agreement with the City or
~~ aaolication for change of zoning mao designation or change to the City's Future Land Use
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 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 EXPE ITUR OR COMPENSATION DURING THE
REPORTING PERIOD. ~ l' ~
of Lobbyist
I do solemnly swear that all of the foregoing facl~ 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 Princi
VI. LOBBYIST IDENTIFICATION: / ~ PRINCIPAL IDENTIFICATION:
~,,~duced ID ~'_~, [Produced ID ~
Form of Identification Form of Identification
~r~...
^ Personally know ;~st ~R HY ~~` Personally known (Pr sh I~IRYHE~IANDQ
11 '":.: MY COMMISSIOW # DD 626373
_.; :.:_ MY COMMISSION # DD 626373 EXPIRF.R May 3, 2011
VII. SIGNATURE A ~ OF X3,2011 ''•~•~` n""N0m'~'~"
~Rt;C~ egged rnn, -Jdery puwc UiMenMters
State of Florida, County of Miami-Da a ate of Florida, County of Miami-Dade
Sworn o a subscribe , of re me Sworn an subscrib b ore me
This ~~ day f d ~ ~ 20~ This ! ~/ ay of A 20 ~
i ~ w
gnatur f u Ne - S of Florida Signature o blic Nota lorida
Notarization of Lobbyist's signature Notarization of Principal's signature
FOR CLERK' ONLY (~°d
Annual Registration fee: [ ~[ ] No Amount Pai MCR # Date Paid
Lobbyist Registration Form received and verified by: ~ ~ ~~
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 0 T , Revised 12/08/04