Form Bso A 165 - Lobbyist Registration Statement Form - Broward Sheriff'S Office, Florida
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1Broward Sheriff’s Office
Lobbyist Registration Statement
Calendar Year _____
Lobbying means communicating directly or indirectly, either in person, by telephone, letter, electronic means, or
other method, with the Sheriff or any other employee of the Broward Sheriff’s Office for the purpose of influencing the
award of a purchasing contract or bid award.
Lobbyist means any person employed, retained, or otherwise compensated by a principal or client who engages in
lobbying.
LOBBYIST INFORMATION
Name:____________________________________________________________________________
(Please Print)
(Last)
(First)
(M.I.)
Address: __________________________________________________________________________
(Residence)
Company
Name: _________________________________________ Telephone Number:__________________
Address: __________________________________________________________________________
__________________________________________________________________________
Email address: _____________________________________________________________________
Do you have any direct business association with a current elected or appointed official or
employee of the Broward Sheriff’s Office? (A Direct business association @ is defined as any mutual
endeavor undertaken for profit or compensation.) ______ No ______ Yes (If yes, please explain. Use
additional sheet of paper if necessary.)
CLIENT INFORMATION
Name: __________________________________ Telephone Number: ________________________
Address: __________________________________________________________________________
__________________________________________________________________________
Subject Matter: ___________________________
________________________________________
General
Specific
CERTIFICATION
I do solemnly swear or affirm that all the foregoing facts are true and correct.
_________________________
_____________
Signature of Lobbyist
Date
STATE OF FLORIDA
COUNTY OF _______________
Sworn to (or affirmed) and subscribed before me this ______ day of ________, 20 ___, by
__________________ (name of person acknowledging).
_____________________________________
Signature of Notary Public – State of Florida
(Print, Type, or Stamp Commissioned Name of Notary Public)
Personally Known ________________ OR Produced Identification ___________________
Type of Identification Produced _________________________________
***
This form should be updated each year***
RETURN COMPLETED FORMS TO: Office of the General Counsel
Copy: HR & Chief of Staff
BSO A# 165 (Revised 02/14)
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