Carol A. Coombes/Miami Gay & Lesbian Film Festival, Inc.,t
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LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed or retained, whether paid or not, by a princpal who seeks to encourage the passage, defeat or mod~cetion 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
acton, decision or recommendation that foreseeably will be heard or reviewed by the dty 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 speclflc exclusions. Please
refer to Ordinance 20043435.
CaaM~~S C-flK~ 0 ~- -~
NAME OF LOBBYIST: (Last) (First) (M.I)
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
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ELEPHONE NUMBER:
LOBBYIST RETAINED BY:
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MI.e,MI R~~C-~i
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NAME OF PRINCIPAUCLIENT:
1~2I -A--ION ~0~1j
BUSINESS NAME AND ADDRESS
I~-~,M1~Mt ~~>4C~
(Number and Street) (City)
is~tate)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
~3 05 5 3'1- 9 9~.4 3 aS ~ 35 Z 3 ~] ~
is a
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:
u.SPECIFIC LOBBY ISSUE: ~ t~ ~ ~ IAN` ~~S i 1~14~- -+4n1~1~~~
C ~ --T~~ ~,t_ 1 0~~ ISM C--r. ~~N i ryot~ -~ ~o~ ~r so ~ ~ ~a~.Lr o~+Jiz-~4~
Issue to be lobbied (Describe in detaip:
ill. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to city code section 2-4s2(g)
include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise to an
appearance ~ 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) ftom 12 months preceding the
commencement of service of City personnel to be lobbied.)
A Full Name of Individual Title B An Financial, Familial or Professional Relationshi
M -d^^- ~C.ta V I S- i Q ~-S
O ~ T', O S .~ v T-~ d E±l T 1'
t1O Kam.
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) ~' S~ 1 ~~ ~ ~r d nnvf'~l
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): ~~~ ~' ~~ ~ ~~- ~ fl(1 V~
(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 ,~No: Are you lobbvinq on a present or pending bid for goods, equipment or services. or on a
present or pending 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':
^ Yes ~ No: Are you lobbvinq on a pending application for a Development Agreement with the City or
application for change of zoning map designation or change to the City's Future Land Use
Map?
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 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 representing snot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
-~Q~titi~f
Signature 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~ of tf}Q Miami Beach City Code and alt reporting requirements.
Signature of lobbyist:
Signature of PrincipaUClient:
VI. LOBBYIST IDENTIFICATION:
l(~'Produced ID ~~~~C~"
Form f Iden
^ Personally known (Lobbyist)
00~~ -~
1 - c-cts;c ~- C C3 aM s; ~ S
PRINCIPAL IDENTIFICATION:
roduced ID ~c ~ / "'
Form of Identification
^ Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTA x o ~., r ~
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State of Florida, County of Miami-Dade ~ ~ =
~
State of Florida, County of Miami-Dade n
~ ~ ~
~
Swom t and subscribe before me
" o o„
T 's ~1 ay of
2008 ~ ~ Swom an subscribe before me
T
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2008 m
,
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Signa of - ate of Florida ~ ~
~ i na r f Public Nota
g ry - tate of Florida ~
Nota ' tion of LobbvisYs signature Notarization of Princiaal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY '
Annual Registration fee: ( }Yes [ j No Amount Paid E M # pate Paid
Lobbyist Registration Form received and verified by:
F:\CLER\LOBBYIST\Lobbyist Registration Form 32708.dat Revised 03/27/2008
i +~ 3 ~
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, F-orida 33139, www.miamibeachH.gov
CITY CLERK Office
Tel: 305.673.7411 ,Fax: 305.673.7254
CityClerk@miamibeachfl.gov
LOBBYIST NAME: ~~ ~d1 GQO ~ f
I understand that no later than October 1st of each veer, 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 withdrawa{ in writing.
~ao~s
Signature:
Date:
F:\CLERIt_OBBYIST1Lobbyist Registration Form 32708.doc