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Rosaris Quinones/MB Watersports Center,_ , 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 prindpal who seeks to encourage the passage, defeat or mod cation of any ordinates, resolution, action or decision of any commissioner, any actiai, decision, naoorrxriendation of the City Manager or any city board or corrirrdttee; or any action, derision or recommendation of any dty peisamel during the time period of the entire decision-making process on such action, derision or rewmmendation that foreseeably will be hearrJ or reviewed by the sty commission, or a dty board or carimittee. The tens sperifically inductee the prfndpal as well as anY employee engaged in lobbying activities, The berm "Lobbyists" has specific exclusions. Please refer bo OMlnance 200-3455. _ ~U ~ ~Jo ~~ 12c~s~-~ ~S NAME OF LOB~BYyIS-T~. p.~(-Last) -~ 1rr~(Fvst) (M I) MJ>~V1 / ~C~ >T~~ WT- I~c~~IpO~~ f'"~E ivi L"/~ ~n /Il~~~rf~~ ~f~ .UF 33 ~~~ BUSINESS NAME AND ADDRESS (Number and Street) ( y) (State] (Zip Code) l ~7 3~ S~3fo l 884/ TELEPHONE NUMBER. FAX NUMBER: EMAIL: I. LOBBYIST/RETAINED 8Y: 1~ 1~7'VI) ©f-~--~ Wfi~1~f~'f5 1~.Grl `~a2 /lam NAME OF PRINCIPAUCLIENT. f ~t /tiJ c7 iA~U C'/2~ tti2 _ M- A~vi-' >~~-~ ~~ x~ i 4 ~ Fill out this section H principal 1s a Corporation, Partnership or Trust [Section 2.482 (c)j • NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: I~oY~Az.D GJ- S ~l~n~ • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% R MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: ~ / p/1 o.SPECIFIC LOBBY ISSUE: ~'~ 1~~ ~"'" ~~acH in/A-~~sr~e~~~-~-s' C~~v"r~2~ if- t i A~1 r' l~~efl ~~ ~/i Trt~ lPL l'G9-~? o /J Issue to be lobbied (Describe in detail. iii. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to city Code section 2~82(g) include a statement of the extent of any business, flnanciai, famiUal, 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(aN4) include a statement of any contractual relationship (paid or unpaid) from 12 rrtontha preceding the commencement of service of Cky personnel to be lobbied.) A Fu ll N a m e Of Individu a l itle T B) An Fina nci a l F am iliac or Professional ReMtlonship ~ / ~ /~ , ,, ~ / - ~ , , //~ ,/~ / ~ ~ / ~ / ~~ :Z ad 4z ~n~ BQpz IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOilRLY, FLAT RATE OR OTHER: A) LOBBYIST DISCLOSURE: (Required) M i0l v B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): A lO , /~ (Required). '" ~l/ 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 oending,award for goods eauitunent or service? 2) Pursuant to Miamr Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": au~lication for change of zoning moo de ianation or change to the Citv's Futurg nd Use IKlafl? 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 2181 above) who only appears as a representative of snot-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. Yea N :Are u re resen n a not-for r fit co ration r enti without s cial com n lion or reimbursement. . V. SIGNATURE UNDER OATH: Signature of Lobbyist: Signature of PrinapaUClie~t R-~'!~-~~l~Jr ~/ %> (~c~ VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: ^ Produced ID ^ Produced ID o~~Q. Form of Identification Form of Identification ~~ ~' ~,, ~,O~~A GS'A~ ~Ty®ae~ ~~`3 Personally known (Lobbyist) SzL~~~t ~ae~Personally known (Principal) ,~~;4~~,~,~a~~k'e #'a'~s~ ZODa ., : . VII. SIGNATURE AND ST ~ij0'>~e #~~y'~~~ 20®~ ~~~~~~~ C~~;'~55~4~C~ ~~.a„~t's~ ~r'~~ ,,550 ~C~ Q9 ," etc. t ' ~x~1~e5•t~QBk~i~ State of Florida, Count of Miam- `' ~'~~ i ~'. ~ ,~,~aF ` ~ ~~~~ Swom to and subscriby fore ~X4~t ~~~pr? State of Florida, County of Miami-Dad ~~~,;~, ~~ E~~~~~, This ~Q_day of J'~~a ha T~m~Q day of before 2008 `'`,, ~/~- ' Sgnature of Public Notary -State of Florida Signature of Public Notary -State of Florida Notarization of Lobbviat's signature Notarization of Prlncioal's signaturo TO BE COMPLETED BY CITY CLERK'S STAFF ONL Annual Registration fee: ]Yes [ ] No Amount Pai MCR aX '° Date Paid Lobbyist Reglstratfan Form received and verified by: F:\CLER\LOBBYIST\toobbyist Reyistrati®n Porm 32708.doc Revised 03/27/2008 r ao solemnly swear that~~h~foregoing facts are true and correct and that I have read or am familiar with the provisions centained in,S 2 2 of the Miami Beach City Code and all reporting requirements. I• City of Miami Bsoch, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office Tel: 305.673.7411 ,Fax: 305.673.7254 LOBBYIST NAME: ,~OSR~ I S C ityClerk@m iam i beachEl.gov Qv r~/n~/~-s I understand that no later than Q~__bber 1 ~t 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 j 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 im~iately notify the City Clerk's Office of lobbyist withdrawal in writing. Si~r~ure: o ao oe F:ICIa~R1LC)BE~YiSTiLobbyist F:egistratiott Forth 32708.r1oc