2013/2014 Collier County Clerk of Courts Expires 0 q 1-)
3299 Tamiami Trail E. (Clerk's office niy)
Suite 401,Bldg. F,4th Floor
Naples,Florida 34112
BOARD OF COUNTY COMMISSIONERS
2,111(1---7 LOBBYIST REGISTRATION FORM
Name /C/(,x10 n.?N Date/O -
Business Name-Pcnbai,c t',yeLel ' • ac� �iF
Business Address 5/06 T ei/rr / j .i 5 /03
City /(},-00e.- -S State /4-4" Zip Code 3
Business Telephone ,;/-634-1) ' Contact Person ,,,/G/,Q 9, ('c.✓v�
Lobbyist E-mail ,e.,/G 4 '`@-t
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 2. Name
Address OP.
�— Address
City Zip Code City Zip Code
3. Name 4.Name
Address Address
City Zip Code City Zip Code
(ATTACH ADDITIONAL CLIENT SHEETS,IF NECESSARY)
State of Florida l�
County of Collier t ,ice f
Lobbyist Si
T i e stration was sworn(or affirmed) and subscribed before me this day of,
, 201-`) , by
e_atAykAl&Ctr_
Personally Known
Produced ID Deputy Clerk/Notary Public
T pe of ID Produced
Revised:08/2011
Receipt# 007388010
10/22/2013 9:22:05 AM
,, Dwight E. Brock
Clerk of the Circuit Court
D
ovi=> Cal
Customer Deputy Clerk Clerk Office Location
DONALD PICKWORTH BMR CASHIER Collier County Govt. Center
DONALD PICKWORTH, P.A. MinutesandRecords @CollierClerk.co Building F, 4th Floor
5100 TAMIAMI TRL N STE 103 m 3299 Tamiami Trail East, Suite
NAPLES, FL 34103-2810 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
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.
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