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2013/2014
Collier County Clerk of Courts Expires g 399Tm2 a f ia i ar Trail E. (Clerk's ice o y) Suite 401,Bldg. F,4th Floor Naples,Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name A-1/11- - V 4 f n Date l ! ` t 3 Business Name - 1 Y1/14M eA Ay e//t(5 Or Business Address 313i i I GAP/a#r i / l/ XI) ty /% 4 f State - Zip Code 3 Y/ 93 Ci � ` Business Telephon 23 Z W �3 Gov Contact Person 21 Ayeir I Lobbyist E-mail d 'I &,r c f (dl14 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.Nameif t)A i &Xi Chic PZ V" 2. Name Address C-0 0 e�Gwa/e 4' . v ` v Address City 4, lo Zip Code / ! 2 D City Zip Code 3.Name 4.Name Address Address City Zip Code City Zip Code (ATTACH ADDITIONAL CLIENT SHEETS,IF NECESSARY) ropp State of Florida IlL ,County of Collier I L byist Sig ature his re .stration) s sworn(or affirmed) and subscrib-d before me this (q.1'{ day of, ,20j),by 1 Personally Known Produced ID / Deputy Clerk/Notary Public Type of ID Produced-\ Revised:08/2011 Receipt# 007378300 9/19/2013 9:16:07 AM Dwight E. Brock Clerk of the Circuit Court r • } LLIf � Lam _ _i i- ' _ Customer Deputy Clerk Clerk Office Location DAVID J. STEVENS BMR CASHIER Collier County Govt. Center INVESTMENT PROPERTIES MinutesandRecords @CollierClerk.co Building F, 4th Floor CORP m 3299 Tamiami Trail East, Suite 3838 TAM IAM I TRL N STE 402 239-252-2646 401 NAPLES, FL 34103-3586 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 Cash Tendered ($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. ©01:1DMQ OQ cgOm Page 1 of 1