Grace Calvani/MB Latin Chamber of Commercem ;11;~r,:,,BFACH
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 includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. 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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TELEPHO NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
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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:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
u.S`PEC'IFIC LOBBY ISSUE.:
Issue to be lobbied`(Describe in detail): lJ L f
m. 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) Any Financial, Familial or Professional Relationship
V rdZ- C.K 3 --none.
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
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B) PRINCIPAL'S DI~CI_(>>URE (CF LOBBYIST
(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 Id No: Are you lobbying 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":
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 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.
Yes ^ No: Are you representing anot-for-profit corporation or entity without special compensation or
' reimbursement. .
V. SIGNATURE UNDER OATH:
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICA'
Produced ID ~~l~~S l..~C.er~e '~~•
Form of Identification
Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribe before e
Tl~' day of ~~~, 2008
nature of Public Notary -State of Florida
otarization of Lobbyist's signature
TO BE COMPI
PRINCIPAL IDENTIFICATION:
Produced fD ~.XI ~'CS ~~~e h S2 ~l~ '
Form of Identification
~~~ "'q{'~y'•.S CYNTHIA M. LEE
I~ rersonally known (Princ f) ~ ;~ MY COMMISSION # DD x36355
t;~-,:gip = EXPIRES: September 7, 2009
Bonded Thru Notary Public Underwriters
State of Florida, County of Miami-Dade
Sworn an subscribe before e
Thisday of _~~~z:x~-~, X2008„
Sig(yz(ture of Public Notary -State of Florida
N arization of Principal's signature
AFF ONLY
Annual Registration fee: [ ]Yes [ ~] No Amount Paid $ rte/ MCR #
Lobbyist Registration Form received and verified by: ~-
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Signature f 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 Sectior~482 of the Miami Beach City Code and all reporting requirements.
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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: ~nrA-C~ C'~.l ucc n i . rera~sen-!~ 1~I ~ (~C~ (~~n` ~~ "~~"~
I understand that no later than October 1st of each dear, 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
2J 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.
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Signatur Date:
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