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
Email: clerkbcc@miamidade.gov
MIAMI-DADE COUNTY
2024 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____.
Type of Identification Produced _______________________
______________________________________
Notary Public in and for the State of _____at Large
My commission expires:
(Notary Seal)
_________________________________________
Deputy Clerk
Fo
r Office Use Only:
An
nual Registration Fee: $490.00 effective through 12/31/2024 Fee Paid: [ ] Yes [ ] No [ ] Cash [ ] Check #_________ [ ] Visa [ ] Master Card
Data Entry Date ___________________________, 20________. Entered By _____________________________________ [ ] American Express
Receipt No._______________________ (
Form Revision Date: 11/30/2022)
ETHICS TRAINING REQUIREMENT
Section 2-11.1(s)(2)(d) of the Code requires each lobbyist to
take an ethics course approved by the Ethics Commission
and submit a certificate of completion to the Clerk of the
Board within 60 days after registration.
Has Ethics Training Been Completed?
(Please Circle) Y / N
If Yes, Date of Completion ___/___/___
