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2013/2014 q 014 Collier County Clerk of Courts Expires 3299 Tamiami Trail E. •(Clerk's office only) Suite 401, Bldg. F, 4th Floor Naples, Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name �ki-01 `-■ -6(... :TT� Date 3 t I l 11--A Business Name cxcc - Business Address -\,--[S.-1 G,)L.- 5 -C� OD. . ---CA-k , S)Ikk— --- City Q■_\l\∎ �� State Zip Code (4(.6--- Business Telephone Z3' '290 -cluF:Y. Contact Person .__ . tus ( 4Li"r) Lobbyist E-mail Gc)`'Ui)U e_c:ri GAS , Y.IEt 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 1 Z-C O L C- S 2. Name Address\430 C 4AL1�-l_5 CD . \JE Address City W 4PA t • Zip Code (00C 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 Lobbyist Signature ttt„.4,.‘,.,,,,,, r, This registration was sworn(or affirmed) and subscribed before me this ``day pi,"—**..r� 4 "=.` N(\A�v c1. , 20 1`t , by ' • Personally Known BY: s roduced ID Deputy Clerk/Notary. ' . r"c, ° . Type of ID Produced RivIpit 2 {1 .:,._ Receipt# 007427485 3/11/2014 12:12:37 PM ,t,,�<<j,,..T Dwight E. Brock ` - `• Clerk of the Circuit Court f 7.: 4 rr;t t:tix ©ffffc6L _�1\c c as — PR Customer Deputy Clerk Clerk Office Location J. DUDLEY GOODLETTE BMR CASHIER Collier County Govt. Center GOODLETTE ATTORNEY AT MinutesandRecords @CollierClerk.co Building F, 4th Floor LAW m 3299 Tamiami Trail East, Suite 4751 GULFSHORE BLVD 239-252-2646 401 NORTH, PH5 P.O. Box 413044 NAPLES, FL 34103 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#8475 ($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. aOU[1 O®G I©lk;TZ❑@C u Page 1 of 1