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2. (Broward County Code of Ethic)
4. Lobbyist Name
6. Email Address
8. Lobbyist Principal or Employer
10. Name of person or entity for whom / which you are lobbying
12. Names of the Town Commissioners / Employees with whom you will be meeting / contacting
14. Names of your employer and / or principal to be present at a meeting / contact with a Town Commissioner at which lobbying activity is to occur
16. Type of scheduled meeting / contact

    1. In-person
    2. Email
    3. Phone
18. Location of "in person" meeting
20. Date of scheduled meeting / contact
22. Time of meeting / contact
24. Description of the purpose and subject matter of the meeting / contact
26. Explain the general and specific matters upon which the lobbyist intends to lobby if known at the time of registration.*
28. If not known at the time of filing, the registration must be supplemented when the matter is determined.
30. Explain business, professional or familial relationship with the lobbyist or their family within the last 24 months.*
32. List campaign contributions to sitting Commission within the past 4 years.*
34. Date of Contribution, Name of Contributor, Commissioner, Contribution Type, Amount*
36. List gifts, including meals, valued over $25, given to Town Official during the past 4 years.*
38. I hereby attest and affirm under penalty or perjury, that the facts contained herein are true and correct.

    I hereby attest and affirm under penalty or perjury, that the facts contained herein are true and correct. Further, I understand that I am required to notify the Town Clerk, in writing, of any changes to the information contained herein and that I am required to complete a lobbyist statement for each new principal or subject matter which occurs throughout the year.

40. The Town Clerk will be notified in writing of any changes to the information contained herein.
42. Signed On This Day*
    Signed On This Day
44. Signed By*
48. Acknowledgement of Receipt
50. Town Clerk
52. Date
    Date
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field