HomeMy WebLinkAboutLobbysist RegistrationNote: Annual Registration Expires on 12/31/2021
CITY OF MIAMI
LOBBYIST REGISTRATION FORM
Instructions: Please complete all sections of this form and submit the completed form, with the applicable
fee(s), to the Office of the City Clerk. If you need more space to complete a section, use a separate sheet(s)
of paper. If you have nothing to report in a particular section, you must type or print "None" or "N/A" in
that section. IF ANY SECTION IS LEFT BLANK, THE FORM WILL NOT BE ACCEPTED.
Important: It is the responsibility of the lobbyist to ensure that ALL active lobbyist registration forms,
including active lobbyist registration forms submitted in previous years, remain up-to-date.
(1) Lobbyist Name: + �� f r le cpe 1 1') S
(Last Nak1je. First vane. Middle Initial)
Are you a Principal of the corporation, partnership, trust, etc.? YES
NO
(vou must check YES or NO)
Business Phone: 3°3 ^ 741 q 7' 76; Email: 1 0 f �i . 1�'� C� N' /.% i'O ()i k j0 VA (Obi
i
Business Address (include Zip Code): '4 . r ;i1 `� t �d i '.+ i- Ji t P ,
r 1.Cif e /I vQ.) 33() MMrerr/' p 33/3 %
(2) Principal Represented: Cr" 3 f v it C. (.2 Vr (e V c,
(3)
(Name of corporation, partnership, trust, etc., you are representing)
Business Address (include Zip Code): C�j 9 f' 5 4A/ } q venue
1'
3 f e 3
IF YOU PROVIDED INFORMATION IN SECTION 2 ABOVE, PLEASE REVIEW TS SECTION
CAREFULLY. If a lobbyist represents a corporation, partnership or trust, the lobbyist must disclose the name
and business address of the chief officer, partner or beneficiary of the corporation, partnership:* trust; and the
names and addresses of all persons holding, directly or indirectly, at (east five percent (5%) o ership
interest in said corporation, partnership or trust. Attach separate sheet if needed. If th)s section is not
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applicable you must type or print "None" or "N/A".
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(4) Specific issue associated with lobbying. Describe ti,itii as much detail as is practical. Attach a separate sheet if
needed. If you are using this form for your Annual Registration, please write "Annual Registration" and the
year that you are registering for (ex: Annual Registration 2020).
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Page 1 of 2
Office of the City Clerk, 3500 Pan American Drive, Miami, FL 33133 / Phone: (305) 250-5361 / Email: clerks@miamigov.com
CM-LRF (Rev. 12/2020)
(5)
Lobbyists shall be required to state the existence of any direct or indirect business association, partnership, or
financial relationship with the Mayor, any member of the City Commission, any member of a City board, the
City Manager or a member of the City staff before whom he/she lobbies or intends to lobby. Attach separate
sheet if needed. If this section is not applicable you mast type or print "None" or "N/A".
I\J(,1i
Lobbyists, as defined in City Code Section 2-653, shall pay an annual registration fee of $55.00, is S105.00 for
each principal represented for each issue Lobbied on behalf of any one principal. Each issue associatewith lobbying
shall be described with as much detail as is practical. The City Clerk, or the City Clerk's designee, all reject any
registration statement that does not provide a clear description of the specific issue on which si ch Iyist has been
retained to lobby or if any section of this form is left blank. Regardless of the date of the annualcregistration, all
lobbyists' annual registrations shall expire December 31 of each calendar year and shall be renewed on a calendar
year basis.
Each lobbyist shall, within sixty (60) days after registering as a lobbyist, submit to the Office of the City Clerk a
certificate of completion of an ethics course offered by the Miami -Dade County Commission on Ethics & Public
Trust ("Ethics Commission"). Lobbyists who have completed the initial ethics course mandated by the preceding
sentence and have continuously registered as a lobbyist thereafter shall be required to complete a refresher ethics
course offered by the Ethics Commission every two (2) years. Each lobbyist who has completed a refresher ethics
course shall submit a certificate of completion within sixty (60) days after registering as a lobbyist.
I do solemnly swear that all of the foregoing facts are true and correct, and I have read or am familiar with the
provisions contained in Chapter 2, Article VI, Sections 2-651 through 2-658 of the Miami City Code, as amended.
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STATE OF
COUNTY OF 1`l 1.,1,ti) @ —' y1d
Sworn to (or affirmed) and subscribed before me by means of
of
(Month)'
(Year)
Signature of Notaryl Public
Personally Known:
Signature of Lobbyist
physical presence or
online notarization, this 1 Wday
by E '',.('.-c I t 'lli� i1'2- g i 'l .1 `1_, Lie_]c
(Name of person makingtstatement)'
OR Produced Identification,
Type of Identification Produced. I
Name of Notary Typed, Printed or Star:nped
NOTARY SEAL)
iP Notary Public Slab of F crlda
Maricerz
"1 . �' IEMY �HI"!H CO:1611
FOR OFFICE USE ONLY: Check #
-T-Tho
Receipt # , cut I
CM-LRF (Rev. 12/2020)
Page 2 of 2
City of Miami
OFRCIAL RECEIPT
Sales Tax $ ' Total $
„Jot 11MAI • „
No. — •
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Datei1
/100 Dollars
Received from: - r C
Address:10i v130,11(14! -El 33 L 1.3)i 31
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For: IlLrOS :14 'ICON_ I9 Reference No: L
By:
Department:_i_ t I •
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Division: 1 't
This Receipt not VALID unless dated,
filled in and signed by authorized em-
ployee of department or division des-
ignated hereon and until the City has
collected the proceeds of any checks
tendered as payment herein.
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