Nancy Ashman/Holland Watters - Johnson Controls, Inc.m J~IAMIBEACH
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 inGudes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 20043435.
NAME OF LOBBYIST: (Last) (First) (M.I)
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I. LOB YIST RETAINED BY:
,C ~ f T Vic?.- ~ ~ N C I ~ 1 ~ ~ :5 VJ ~.~i +_~ S i . ~ "! r: ~ ~ I ~`~ I t~-~ M ~ (<~ ~" r--
AND ADDRESS (N ber anti Street) (City) (State) (Zip Code) 3 ~ 02'7
3~r~~>39 ~''~~.~)s3~-BSc°3
is a Corporation, Partnership or
• 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):
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III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to city code section 2~s2(g)
include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise to an
appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code Section 2-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the
commencement of service of City personnel to be lobbied.}
A Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship _ _~
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) ~-.~ ,,i ~ ~ ~ i ~ ~ ~ ~,! ~L `~ ~~ -}- ~~~ti±~,) S
B) PRINCIPAL'S<AISCLOSURE (OF LO ~ `r)IST MPhENSATIC~JJ~ / I J1
(Required). ~i r .. f ~ P 1- ~t ,/s,~ C r'1 °' .~
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':
/ ` present or pendina 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':
application for chance of zoning map designation or chance to the City's Future Land Use
Man?
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 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.
reimbursement. .
V. SIGNATURE UNDER OATH:
, v~ :H afar anu~n
pYi
'~/~. ~~ ~; Notary r ubGc -State of Florida
`(; Irv . "==Nty Corm, sio ti Expires Pag 14, 2009
,; Signatu Lobbyist
. 13~n u, c Natrona'. , iotary Assn.
~i~~ ng facts are true and correct and that I have read or am familiar with the
provisions contained in Se~jo -482 of the Miami Beach pity Cody and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
~~Produced ID ~~ /?ic'',`Lfr'f°.4 /, Cl'/>Sc" 0 Produced ID
Form of Identification
PRINCIPAL IDENTIFICATION:
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Mirnni-i3sde S I 7c'%f~-~
Sworn to and subscribed before me
Th~is /~~ day of ~''~ , 2008
Signature of Public Notary -State of Florida
Notarization of Lobbyist's signature
Form of Identification
NOTARY PU>SLIC-STATE OF FLORIDA
Personally known (Principal) ""'••. MariOII Gail 1i08Se
'` Commission #~ DD710963
1 ,,,, . ~ Expires: SEP.10, 2011
BOI~iDED TfI1tU AT(ANTIC SQNDIHG CO., INC.
State of Florida, County of Miami-Dade
Sworn aRd subscrib d bef re me
T is I ~~ day of ^ ~~; 008
` ^- ~-n--
gnature of Public Notary -State of Florida
N tarization of Principal's signature
TO BE COMPLETED BY CITY C ERK'S STAFF ONLY
Annual Registration fee: [ ]Yes [ ] No Amount .aid $ /2 MCR # U Date Paid /
Lobbyist Registration Form received and verified b
Revised 03/27/2008
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: ~ 1~1 C ~ +~ /-~
I understand that no later than October 1st of each ear, I must file the following
forms, pursuant to Section 2-485 of the Miami Beach City Code, with the City Clerk's
Office for all active lobbying issues.
1) Lobbyist Expenditure Form
2) Disclosure Form
Failure to file these forms on a timely basis will result in my name being transmitted to the
Miami-Dade County Commission on Ethics and for code violation evaluation.
In addition, once an issue I have registered to lobby on has been resolved, I am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
Signature: Date: