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2012/2013 Collier County Clerk of Courts Expires / 2D I 3299 Tamiami Trail E. (Clerk'spffice only) Suite 401,Bldg. F,4th Floor Naples,Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name C ( Wit N C c S ' 1 is t4 vi--S �E, Date 2`f AA h "I 2 0 f 3 Business Name Business Address 13 10 (A/4-- wt 6 7-0 ya-t,, r£ City k) 0 l-t S State F L Zip Code Y / /I Y Business Telephone 23 5 3 7 —P 8 CS Contact Person Lobbyist E-mail CA—el.f` S Cb in t Cups 4- • NI 2.+ Notice for Lobbyists: The annual registration fee is $25.00 per Lobbyist, per Collier County Ordinance No. 2003-53, and amended by Ordinance 2004-05 and Ordinance 2007-24. Payments made out to: Collier County Clerk of Courts or Dwight E. Brock, Clerk of Courts (ADDRESS LISTED ABOVE) NAME AND ADDRESS OF EACH CLIENT/ENTITY REPRESENTED: 1. Name C t ki 0 tz 0...HscG,L.A be_S C.A. 41 Name Address -k)-O • (3 oX 1(t7 1 Address Citylu tilt to t.r�n-e,4- 41 Zip Code 3 y l 3 j City Zip Code 3. Name 4.Name Address Address City Zip Code City Zip Code (ATTACH ADDITIONAL CLIENT SHEETS,IF NECESSARY) State of Florida / _/.. County of Collier /AMIGL Lobbyist Signature s ), T is registration was sworn(o affirmed) and subscribed before me this.)"' ,t day-of, , 2013 ,by Lein, , • , <� , • _Personally Known BY I �' �' 42' Produced ID ' Deput`y,Clerk/Not., ' e+ttbli �� Type of ID Produced y;, ;U. Revised:08/2011 Receipt# 007343403 5/24/2013 1:36:52 PM �,,«< ,,,,,� Dwight E. Brock j, Clerk of the Circuit Court l Y R . fit;. , 11 ray _ ,�� ( C ` �� e @c _ r1J#i;3;;C.� Customer Deputy Clerk Clerk Office Location CLARENCE S. TEARS JR. BMR CASHIER Collier County Govt. Center EVERGLADES CITY MinutesandRecords @CollierClerk.co Building F, 4th Floor 1320 LAMBTO LANE m 3299 Tamiami Trail East, Suite NAPLES, FL 34104 239-252-2646 401 P.O. Box 413044 Naples, Florida 34101-3044 1 Product QUANTITY DESCRIPTION UNIT COST AMOUNT 1 BMR Lobbyist Registration $25.00 $25.00 TOTAL AMOUNT DUE $25.00 Check# 3546 ($25.00) BALANCE DUE $0.00 Note: Disclaimer: All transactions are subject to review/verification. The Clerk reserves the right to correct for clerical errors and to assess or refund charges as needed. ©diEC ITagrilho gOn Page 1 of 1