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a
BROWARDHEAHH'
NORTH BROWARD HOSPITAL DISTRICT NBHD) DBA BRO\ryARD
HEALTH LOBBYING REGISTRATION FORM
(SEE BACK FOR INSTRUCTIONS)
To which fiscalyear does this form apply? 29 '18119
ffin"n"*.t
For what purpose are
you
this form?
to Profile
New Registration
Last Name First Name9915 Equus Circle Bovnton Beach, Florida 33472
Email Addresst 9il t 281-1202Office Number
Cell Number
Pamela
Middle
oamela.
Mailing Address
LOBBYIST:Jones
Lobbying Firm on behalfofwhich lobbyist is representing principal (ifany)
Lobbying Firm's Mailing Address
Telephone Number
Provide the names. business address, telephone number and area ofinterest ofeach principalrepresented.
industrv and Medtronic oroductsAreas of Interest/General & Specific Sub.ject Matter
Medtronic, lnc.
All matters affecting the healthcare
PRINCIPAI, #2
Principal Name
Principal Mailing Addrcss
Areas of InteresVGeneral & Specific Subject Matter
PRINCIPAL #3
Principal Name
Principal Mailing Address
Areas of lnteresVGeneral & Specific Subject Matter
710 Medtronic Parkwav. LC370
PRIN(]IPAI, #I
Principal Name
Principal Telephone Number
505-2597
Principal Mailing AddressMinneapolis. Minnesota 55432-5604
(_) _Princ,pal Telephone Number
Have you ever been an employee of Broward Heahh? { *o Yes,
Have you ever served as an NBHD Commissioner or on a Commission SuECommittee?
Date of Service
Date of Separation
Title
Date olEmployment
Date of Separation
/ *o Yes,
My Comm.
July 4,2021No. Gc 12102
$
before me
day of
(Signatuie of Notary Public-State of Florida)
Dz-
r
nature of
and
St
20
ib ,,
(or
(Print, Type, or Stamp Commissioned Name of
Type of ldentification Produced
Personally Known
STATE OF
COUNTY OF
OATHI do solemnly swear that all the foregoing facfs are true and correct.
ORh,
PAGE 1
c--203-r
Do you have any direct or indirect business association. partnership, or financial relationship or live inthe same household with or are related to any Broward Health Board Member, Board CommitteeMember, employee, or agent?d t" D Yes. State with whom and explain: -
, l_Principal Telephone Number
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