2013/2014 a
Collier County Clerk of Courts Expires ep.
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 720N -741-- lif f't'' e- Date O G a ' 2 O l3
Business Name p D 6 647 41 SS oG /,9 4-r •
Business Address o 7/4 171 2a/j tm• J !4- Z
City AA 4G'1'eh' State /2L ' Zip Code ? 4/1/ 4'
Business Telephone s �� 'Y/' Contact Person
Lobbyist E-mail r1 D Z-zi C O S 9 e -' f IV e— y 4h p d . G p m
Notice for Lobbyists: The annual registration fee is$25.00 per Lobbyist, per Collier County
Ordinance No. 2003-53, and amended by Ordinance 2004-05 and Ordinance 2007-24.
Payments made out to: Collier County Clerk of Courts or Dwight E. Brock,Clerk of Courts
(ADDRESS LISTED ABOVE)
NAME AND ADDRESS OF EACH CLIENT/ENTITY REPRESENTED:
1. Name , /47m ' 'Q 2. Name
Address 76'°'° -S 046+-',9 "' 4 5$ Address
City Sal/1/72; €- Zip Code 3 33 2-3 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
T, is re istratio was sworn(or armed)and subscribed before me this day ••
GC11DW, 201, , by Ua y of
J V✓lV•
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Personally Known BY: Ct
y- Produced ID L
,r-.,/ �� Deputy otary
Type of ID Produced t'Ci
Revised:08/2011
Receipt# 007382079
10/1/2013 11:27:15 AM
Dwight E. Brock
Clerk of the Circuit Court
( 0 EN°, D) o — ER
Customer Deputy Clerk Clerk Office Location
ROBERT DUANE BMR CASHIER Collier County Govt. Center
ROBERT DUANE & MinutesandRecords @CollierClerk.co Building F, 4th Floor
ASSOCIATES m 3299 Tamiami Trail East, Suite
4880 TAMARIND RIDGE DR 239-252-2646 401
NAPLES, FL 34119-2826 P.O. Box 413044
Naples, Florida 34101-3044
1 Product
QUA NTITY DESCRIPTION UNIT COST AMOUNT
1 BMR Lobbyist Registration $25.00 $25.00
TOTAL AMOUNT DUE $25.00
Check#9998 ($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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