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2011/2012 Collier County Clerk of Courts Expires 3299 Tamiami Trail E. (Cler s office only) Suite 401, Bldg. F, 4th Floor Naples,Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name v ),1 LL TG/(u) i2 71( Date /D—/3— /1 Business Name-7)d ti 1._b 4 . Pe/6J d yz_7-c4 P4 Business Address .5-75?) 49Vi, f T'eZ- City 71/1�3 State FL Zip Code 3 y/D3 Business Telephone, �"--2?6V. Contact Person c...,1(c_t)O 1c-7 Lobbyist E-mail p c /ce w E?a✓ /c n.k. X fi 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 PTV G4 776- D UL.Pil .oT 2. Name Address 5 � -S /11/9/1`) 57 Address City 4/(AD' t5)4- Zip Code 603 ? 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 .0/ �V/ obbyist Signature This registration was sworn (or affirmed) and subscribed before me this / day of, a7[ " , 20// , by -D09J ALb A'. P tG K.[D 0R:?'f , V Personally Known ti ANGEIA`TOMPKINS � Commission#DD 93276E Produced ID ilk' Ego pTm ,o 9 Deputy Clerk/Notary Public Type of ID Produced Revised:08/2011 Receipt# 007195609 10/17/2011 3:34:48 PM z<�,; Dwight E. Brock (::%::,) 1 ' Clerk of the Circuit Court K,,,___ 'f• * /:3)1 ---------, fa EI EI ,-- .,,_____ (-_, R c, L.7._ (,_.-2) — c,_, ,,, if9D Customer Deputy Clerk Clerk Office Location DONALD A. PICKWORTH, BMR CASHIER Collier County Govt. Center P.A. MinutesandRecords @CollierClerk.co Building F, 4th Floor DONALD A. PICKWORTH, m 3299 Tamiami Trail East, Suite P.A. 239-252-2646 401 5150 TAMIAMI TRL N STE 502 P.O. Box 413044 NAPLES, FL 34103-2822 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#5779 ($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. ©glErl®Ta®DtZoggED Page 1 of 1