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2. 

4. Please complete a lobbyist registration form for each person or entity on whose behalf you have been engaged to lobby. There is a $50 fee for each registration. Payment may be made in person at Town Hall (4501 N. Ocean Drive) during normal business hours or online by entering your credit card information below. 

   By providing your credit card information you are authorizing the Town of Lauderdale-By-The-Sea to charge your credit card $50. 

   After your payment has been processed you will receive an email notification from the Town Clerk indicating that your registration is complete.

6. Lobbyist Name*
8. Lobbyist's Address*
10. Lobbyist's Employer*
12. Lobbyist's Employer's Address*
14. Nature of Lobbyists Business (e.g., lawyer, consultant, contractor)*
16. Client Name*
18. Client's Address*
20. Lobbyist's Email*
22. Lobbyist's Matters of Interest*
24. Direct Business Associations between the lobbyist and any current elected or appointed official or employee of the Town*
26. Payment Information
28. Credit Card Type

    1. Visa
    2. Mastercard
    3. Discover
    4. American Express
30. Name as it Appears on Credit Card
32. Credit Card Number (no spaces)
33. Credit Card Security Code
34. Credit Card Expiration
36. Terms of Use Agreement

    I, the undersigned, do hereby swear, under penalty of perjury, that the information furnished below is true and complete to the best of my knowledge.

    • I am the person who has signed up for, and is identified by, my password and user ID as the lobbyist.
    • I understand that I may not share my password or user ID with any other person, because my password and user ID are the equivalent of my signature.
    • I understand that I must register as a lobbyist in Lauderdale-By-The-Sea for each Client I am representing within 10 days of beginning my lobbying activities.
    • I am authorized by each Client by whom I am employed to legally certify and make filings required by the Broward County Ethics Law.
    • I understand that I will be personally and legally liable for the veracity, accuracy, and timeliness of all information submitted under my password and user ID, including any information filed without my consent or knowledge, as a result of any failure by me to safeguard and keep confidential my password and user ID.
    • I accept all applicable legal and financial liabilities, including for perjury, if any submitted information is not true, complete, or timely filed.
    • I understand that if I authorize anyone else to perform data entry tasks for required filings on my behalf, it will still be my responsibility to review, file, and sign these entries certifying the completeness and accuracy of such filings.
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38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field