Conni Gordon/The Conni Gordon Arts FoundationMIANtIBEACN
City of Miami Beach Office of the City Glerk
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 a decision of any rnmmissioner; any action, decision, recommendation of [he
City Manager or any city board or committee; or any action, derision or recommendation of any dry personnel during the time
period of the entire derision-making process on such action, derision or recommendation that foreseeably will be heard or reviewed
by the city commission, or a city board or committee. The term spedfxally includes the principal as well as any employee engaged
in lobbying activities. The teen "Lobbyists" has spedfic exclusions. Please refer to Qrginance 2004-3435.
NAME OF LOBBYIST: (rast) / (First) (M.I)
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NUMBER: FAX NUMBER: EMAIL:
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I. LOBBYIST RETAINED BY: ~GT'Wa~ ~O'~-zJ ( --~- ~
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AME OF PRINCIPAUCL[ENT:
BUSINESS NAME AND ADDRESS (Number arM Street) (Ci (State) (Zp Code)
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NUMBER: FAX NUMBER: (Optional) (/ EMAIL:
cot this section if prindpal is a Corporation, Partnership or Tr~ustQQ[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: C /~
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Issue to be
IIL CITY AGENCIES/INDMDUALS TO BE LOBBIED:
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B) Any Fnancial, Familial or Professional Relationship s
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
fLAT RATE OR OTHERj.
A) LOBBYIST DISCLOSURE: (Required) ~-
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required}~J
The fallowing information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
Mao?
3) Pursuant to Miami Beach Ciry Code 2-464 (h) Any person (except those exempt from the definition of
"lobbyist" as set forth in Section 2-4B1 above) who only appears as a representative of anot-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..
Yes ^ No: Are you reoresentina anot-for-Drofit mroaratian or entity without soecial comcensation
l " or reimbursement. .
V. SIGNATURE UNDER OATH:
requirements.
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 EXPENDITURES OR COMPENSATION DURING THE
REPORTING PERIOD.
Signatu 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 reoortina
Signature of
Signature of
VL /LOBBYIST IDENTIFICATION:
S ~ D' Produced ID ~~'~j~r~ 02 3 ~~
[3 ~ Form of Identification
LL q
~y9i o .. n
g o Personally known (Lobbyist)
'M I. SIGNATURE AND STAMP OF NOTARY:
of
to of Florida, County of Miami-Dade
orn to a d subscrib d before me `~
is day of ~, zo ~ b
..... t ./~ .. 1 . n
~blic Notary - State"of Floi
of Lobbyist's signature
PRINCIPAL IDENTIFICATION:
c~roduced ID ~ ~ 3J~ IO~~-3
Form of Identification
^ Personally known
tr~Y Fupyc • Stob of Flow
''~?~'Q.':~ C~mWbrt+MDDJI64gq
State of Florida, Cou `~~ BVNallppl ,~
Sworn a subscri before me
This cZ day of~, 20r7
Signature 6~f Public Notary -State ofate of Florid!
Notarization of Principal's signature ~ Ul ~f ~~~~
FOR CLERK'S USE ONLY
Annual Registration fee: [ ]Yes [ ] No Amount Paid ~~ MCR #
Lobbyist Registration Form received and verified by: i
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM OS ~ oc
Paid
Revised 12/08/04