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Mike Adams/World Waste Services\ ~..~ r ~ i 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 baard 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 ar recommendation that foreseeably will be heard or reviewed by the city ~mmission, 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 rehr to Ordlnanee 2004.3435. NAME OF LOBBYIST: ~ ~©~ ~ ~_A ~C`~~ BUSINESS N(AM~E~AN/D,.ADDRES(S~ . TELEPHONE NUMBER: I. LOBBYIST RETAINED BY: NAME OF PRINCIPAUCLIENT: BUSINESS NAME AND (Last) ~ (First) (Number and Street) (Giry) ~~~~~~~ (M.I) ~ I ~ y-Y~ l ~33j~a EMAIL' (~~~~ecs~~~~tee~a cc rn-S and Street) (City) (State) (Zip Code) m+ ~~a TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) (~U Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)j SQ/u1C° 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: n.SPECIFIC LOBBY ISSUE: Issue to be lobbied (Describe in detail): 111. CITY AGENCIESIINDIVIDUALS 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(aN4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the cotrttdehcement of service of City personnel to be lobbied.) A Full Name of Individual Title B) An Financial, Familial or Professional Relationship ~~ ~ W1~y~'''1t~1 fJ A) LOBBYIST DISCLOSURE (Required} ~ i• ~ ~ . ~ ~ ~! B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATIO {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 lobbvina on a present or pending bid for goods egu~oment or sernces or on a »resent or pend~na 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": 0 Yes ~ No: Are you lobbving on a pending application for a Development Agreement with the City or aPphcabon for change of zonmg map des~anation or change to the Citv's Future Land Use Map? . 3) Pursuant to Miami Beach City Code 2-464 (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. 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 C~ Code and all reporting requirements. Signature of Lobbyist: /~~ Signature of Principal/Client: --~,~~~~ ~. LOBBYIST IDENTIFICATION: ~~,, // r LllrProduced iD r Form of idenl ^ Personally known (Lobbyist) VII. SfGNATURE AND STAMP OF State of Florida, County of Miami-Dade Sworn to and subscribed efore me This ~~ of _S~ , 2008 Sig ature o u ~c o ary - tate of Floi Notarization of Lobbyist's signature PRINCIPAL IDENTIFICATION: 1 I~'Produced ID QG ~ ~ _ Form of Identification o~~ ~ ^ Personally known (Principal) .. '" ~ ~ ~~~ r >Nw ~ ~ ~ St ~~~ a ~ ~ w ~ ~ ate of Florida, County of Miami-Dad Sworn an~subscribed bef re me This day of ~s~v , 2008 ~ ~. :~?~~ I of PrincipaP's To BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes [ ) No Amount Paid 5 MCR # ~ Lobbyist Registration Form received and verified by: F:\CLER\HATL\Formz ,~obby •. F.=y.- ;, F~, ~.nr•. v- ~G- ~ J of Paid Revised 03/27/2008 Signat re of Lobbyist t ~~~ ' City of Miami B®och, 1700 Convention Center Drive, Miami Beach, Florido 33139, voww.miamibeachfl.gov CITY CLERK Office CityClerk@miamibeachFl.gov Tel: 305.673.741 1 ,Fox: 305.673.7254 LOBBYIST NAME: I understand that no later than October 1st of each xear, I must file the fol{owing 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. !n 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. ~~~ ~~Q~ v Signature: Date: f~~~visad o~roa.;~oos s' j ~a ~ i 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: I understand that no later than October 1st of each year, I must file the fol{owing 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, f am required to immediately notify the City Clerk's Office of lobbyist withdrawal in writing. ~ ~ ~~d~ Signature: Date: r~avisaca o2roa.~2oos