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2013/2014
Clerk to the Board,Minutes &Records Dept. Expires 01-Q t / 3299 Tamiami Trail East, Suite#401 (Staff use only) Building F,4th Floor Naples, FL 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name A lcve.ot DOU5(1t Date S 1 I i Business Address l (DC(qQ L l vi ilS t3(tpk${ �L 31/1 /0 Business Telephone 23 " 12 l"tolgg E-Mail advU5 -'C°')?Gj rs C 147) NAME AND ADDRESS OF EACH PERSON OR ENTITY REPRESENTED: 1). kl,--s(DI 196.r6-itiZ IOCK l�Av t k_5S-Ezm lam• Ii 04 Vs R, 3y l t v 2). (PLEASE ATTACH ADDITIONAL SHEETS,IF NECESSARY) i 'IL ice. A Lobbyist Signature State of Florida County of Collier The foregoing registration was s orn to and subscribed before me on th' - day of ji -Zo t`-f ,by 1cfesit bat)jk.ort , who i .ersonally known to me or has produced as to en i Ica ion and who did take an oath. ie"" l.: UR1E JACKSON 1 f i?Y COMMISSION#EE67360 BY: 401 Y?IRES:March 12,2015 �� Fl.Notary Discount Assoc.Co. Deputy Clerk/Notary Public 1-800-3-NOTAkY The annual registration fee is $25.00 per Lobbyist,according to Collier County Ordinance No.2003-53, as amended by Ordinance 2004-05,Ordinance 2007-24 and Ordinance 2013-39. Please make payment to: Collier County Clerk of Courts or Dwight E. Brock,Clerk of Courts and mail to the address listed at the top of the form. Receipt# 007463128 6/25/2014 3:51:25 PM Dwight E. Brock Clerk of the Circuit Court I Customer Deputy Clerk Clerk Office Location KITSON EVERGREEN LLC BMR CASHIER Collier County Govt. Center 4500 PGA BLVD STE 400 MinutesandRecords @CollierClerk.co Building F, 4th Floor PALM BEACH GARDENS, FL m 3299 Tamiami Trail East, Suite 33418-3995 239-252-2646 401 P.O. Box 413044 Naples, Florida 34101-3044 1 Product QUANTITY DESCRIPTION UNIT COST AMOUNT 5 BMR Lobbyist Registration $25.00 $125.00 TOTAL AMOUNT DUE $125.00 Check# 12226 ($125.00) 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. ©®0D[1QT@OQgall10 Page 1 of 1