For Office Use Only: Check#__________________ Receipt#_________________ CITY OF MIAMI LOBBYIST REGISTRATION (1) Lobbyist Name: Last Name, First Name, Middle Initial Business Phone: Business Address Zip E-Mail Address (2) Principal Represented Principal’s Business Address Zip (If different from above) (3) Specific issue lobbyist has been retained to lobby (if representing a corporation, partnership or trust, give business address of chief officer, partner, or beneficiary of same, and the names and addresses of all persons holding, directly or indirectly, at least five percent (5%) ownership interest in said corporation, partnership or trust). (4) Lobbyists shall state the extent of any business association or financial relationship with any member(s) of the City Commission, any member of City staff before whom he/she lobbies or intends to lobby. (If applicable, please explain) Lobbyists shall pay all registration fees ($500.00 annually, plus $100.00 for each principal represented and for each issue a lobbyist has been retained to lobby on behalf of any one principal), and specifically define the issue for which they are employed. The Clerk shall reject any statement which does not detail the issue for which the lobbyist has been employed. 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 Sections 2-651 through 2-658 of the City of Miami Code, as amended, including “annual registration, withdrawal, reporting requirements, definitions, examinations, penalties for violations and contingency fees.” Lobbyist Signature State of Florida, County of Miami-Dade Sworn to and subscribed before me this day of , . Notary or Deputy Clerk Note: Annual Registration Fee: Effective through 12/31/2010 American LegalNet, Inc. www.FormsWorkFlow.com