MIAMI-DADE COUNTY LOBBYIST ACTIVITY AUTHORIZATION Section 2-11. 1(s) - Code of Miami-Dade County Florida Please Type or Print in Ink Principal’s Name Principal’s Contact Person Principal’s Trade Name Mailing Address Telephone Number Other Principal(s) of Interest holding directly or indirectly a 5% or more ownership interest. Name Of Lobbyist(s) Lobbyist’s Address Note: It is the responsibility of the lobbyist to notify the Clerk of the Board of County Commissioners of any changes in address. Telephone Number Date Employed Note: 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. c Please check here if the lobbyist is employed for a specific issue. Specific Issue: I swear under penalty of perjury that the information on this form is true and accurate. Principal’s Signature: Date: / / Pursuant to Section 2-11.1(s)(9) of the Code of Miami-Dade County, misrepresentation on this form may subject a person to prohibition from lobbying before the County Commission or any committee, board or county personnel for a period not to exceed five years. For Office Use Only: Data Entry Date ___________________________, 20_______. Entered By _________________________________________________________ (Form Revision Date: 8\18\05) 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.miami-dadeclerk.com/dadecoc/Clerk_Board.asp American LegalNet, Inc. www.FormsWorkflow.com