MIAMI-DADE COUNTY 2012 ANNUAL LOBBYIST REGISTRATION Section 2-11.1(s) - Code of Miami-Dade County, Florida Please Type or Print in Ink Date: _______/_______/_______ Mr/Ms Last Name First Name Mi. Business/Firm Name Address ____________________________________ ________________________ _____________ City State Zip Note: It is the responsibility of the lobbyist to notify the Clerk of the Board of County Commissioners of any changes in address. ____________________________ ________________________ Business Phone Fax ________________________ E-Mail Please indicate if you are representing a  Not-for-Profit Agency or  if you are the principal of, and are only appearing as a representative of one of the following groups without special compensation or reimbursement for the appearance, whether direct, indirect or contingent, pursuant to Section 2-11.1 (s) 3(b) and 4 of the Code of Miami-Dade County (Please check applicable group):  Certified Level 1 C.S.B.E  Certified Micro Enterprise  Certified Tier I Community Business Enterprise  Corporation, Partnership or other Entity OATH I do solemnly swear that all facts contained on this Annual Lobbyist Registration form are true and correct; and that I have read and am familiar with the provisions contained in Section 2-11.1(s) of the Code of Miami-Dade County. _________________________________________ Signature of Lobbyist State of _____, County of __________________ Sworn to and subscribed before me this ______ day of ______________, 20____. By _______________ who is personally known _____ or produced identification ____. PLEASE NOTE: Type of Identification Produced __________________________ ON OR BEFORE JULY 1ST OF EACH YEAR, EVERY LOBBYIST MUST FILE AN EXPENDITURE STATEMENT WITH THE CLERK OF THE BOARD OF COUNTY COMMISSIONERS FOR THE PRECEDING CALENDAR YEAR, REGARDLESS OF THE LEVEL OF ACTIVITY OF THE LOBBYIST, AND WHETHER OR NOT THE LOBBYIST HAS INCURRED ANY EXPENSES DURING THE REPORTING PERIOD. ______________________________________ Notary Public in and for the State of _____at Large My commission expires: (Notary Seal) _________________________________________ Deputy Clerk For Office Use Only: Annual Registration Fee: $490.00 effective through 12/31/2012 Data Entry Date ___________________________, 20________. Fee Paid: [ ] Yes [ ] No [ ] Cash [ ] Check #_________ [ ] Visa [ ] Master Card Entered By ______________________________________ ___________________ (Form Revision Date: 8/24/2011) Clerk of the Board of County Commissioners, 111 NW First Street, Suite 17-202, Miami, FL 33128 Office: 305 375-5137 - Fax 305 375-2484 www.miamidade.gov/cob Email: clerkbcc@miamidade.gov American LegalNet, Inc. www.FormsWorkFlow.com