Mitchell A. Bierman/Waste Services, Inc.j^i
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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 prinripal who seeks to encourage the passage, defeat or modification of
any ordinance, resolution, action or derision of any commissioner; any action, derision, recommendation of the City Manager or any city board or
committee; or any action, derision or recommendation of any dty 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 rity commission, or a city board or committee. The term
sperifically indudes the prindpal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusion ~ Please
refer to Ordinance 2004-3435.
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NAME OF LOBBYIST: (Last) (First) (M.I)
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BUSINESS NAME AND ADDRESS ~ (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
1. LOBBYIST RETAINED BY•
NAME OF PRINCIPAUCLIENT: '
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BUSINESS AM AN ADDRESS (Number and Street) (City) (Slat) (ip Code) ,
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FAX NUMBER: (Optional)
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out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
• -DENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
u.SPECIFIC LOB~Y IS ;UE:
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ul. 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 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) An 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): ( J_ /
A) LOBBYIST DISCLOSURE: ~e"7<T~ ~ `~~OV~~~ - mil-' f 4,r~ a~'1~n~ ~b ~ Gt~~P~M~nP / ~y n~nt 1 ~, o'{ /)(OtI/',j,~
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 L~'No: Are you lobbvinq on a present or pending bid for Qoods, equipment or services, or on a
present or pending award for Qoods. equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes L_Y'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 Citv's Future Land Use
Map?
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.
^ Yes No: Are you representing snot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
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 reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
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NCIPAL IDENTIFICATION:
~ Produced ID
Form of Identification
Personally kn ,~;~ c~pal)FLOSSIEM.JORDAN
.,,: MY COMMISSION # DD 519949
EXPIRES: March 2, 2010
:?~~~c; Bonded itxu Notary Punic Underwriters
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State of Florida, iami- ade
Sworn and subscribed before me
This j5thday of , 2008
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Signature of Public''Notary -State of Florida
Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes [ ] No Amount Paid S~ MCR #r Date Paid
Lobbyist Registration Form received and verified by:
F:~CLER~LOBBYTST1Lobbyist Re~gistc•~stian Farm 82708.dae ~ Revised 03/27/2008
Form of Identification
AND STAMP OF NOTARY:
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Signature of Lobbyist
Personally known (Lobbyist)
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CilyClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYI T NAME• l~G~~JI ~~ p~/~dn
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I understand that no later than October 1st of each year, 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.
L
Signature: Date:
F:IGLEFi~L08BY1S`11Lab1)yist f2egistration Form 32708.doc
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