Christopher Colgan/Exclusive Sports Mktg~ ~~~~~ ~~~~~
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, 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 refer to Ordinance 2004-3435.
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NAME OF LOBBYIST: st) (First) (M.I)
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BUSINESS NAME AND ADI~RESS (Number and S~"c~et) (City) (State) (Zfp Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
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I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAL/CLIENT: ~> ~ ~
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) -r'{Zp ~^jde) ,..
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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:
II. SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title ~ B) Any Financial, Familial or Professional Relatio~ship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER~
A) LOBBYIST DISCLOSURE: (Required) ` 3 1 I'~
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":
~r~nt or uendina award for aoods eauioment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled ~~Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
DYes ~i No Are vou lobbvina on a oendina au~lication for a Develoument Aareement with the Citv or
~plication for chanae of zonina maa desianation or chanae to the Citv's Future Land Use
Ma°?
3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of
'~IobbyisY' as set forth in Section 2-481 above) who only appears as a representative of a not-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..
o Yes C~No• Are vou re~resentin4 a not-for-orofit corooration or entitv without saecial compensation
~ or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1~ OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CL A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPEND , AS L AS OM NSATION
RECENED, IN THE CTTY OF MIAMI BEACH FOR THE CEDING CAL DA YE . A ATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EX'~ENDITURE O COM N TION URING THE
REPORTING PERIOD. f
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I do solemnly swear that all of the f 'ng fa r true and rre and that I have read or am
familiar with the provisions contai in i 2-48 of the M' mi ach City Code and all reporting
requirements. ~. /'
Signature of Lobbyist:
Signature of Principal/Client:~--'"~T ! ~
VI. LOBBYIST IDENTIFICATION: `"'~~PRINCIPAL ID NTIFICATION:
~~ Produced ID
Form of Identification
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~ U~~,~v~ (Lobbyist)
_ ~ . ~y~I~~.~~ A~lD STAMP OF NOTARY:
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State of Florida, County of Miami-Dade
Sworn t and subscribe before me
This day of 200~
Si na re of otary - State of Florida
rization of Lobbyist's signature
^ Produced ID
Form of Id~'~t~A~3.~.Q..~.A...~e....oe~».,.~..
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,~ersonally known (Princi~ '~ CW~m;~Ci~C~1R~:.9
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State of Florida, County of Miami-Dade
Sworn and subscribed before me
This 1Lday o 20~
Signature o Publ te of Florida
Notarization o Principal's signature
~ FOR CLER '-~,~YL.Y ~q~ I y~ O
Annual Registration fee: [ ] Yes [ ] No Amount Paid CR # I Date P id
Lobbyist Registration Form received and verified by: . ~
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc ~ Revised 12/08/04