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2012/2013 Collier County Clerk of Courts Expires V2.013 3299 Tamiami Trail E. (Coffice only) Suite 401,Bldg.F,4th Floor Naples, Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name JQ,r-1e.`; T at-A-on Date i.`c ( 2101 Business Name (- 1 cc)(-} —t'c A I. A . Crl.ine > j 1 �.)o'\ Business Address J(o ,( eic,i. n t ./e-4'1Ue.1 S-. 4CCc) City c��ca.(C, State Zip Code I.4-c.,M . Business Telephone 7.(C - e52.-c>'- I(3 7 Z Contact Person(c : 'i. Qn CZj).:,p ii)Ci Lobbyist E-mail Jd 4--i,,)y ,C X9(.1.r ea EJe�Gp mean+ Czrn 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 (73-a_ e,5 e,5 F De_y'4- ,,3e,--- 2. Name Address �j ., 0e ,,,,,,re, A-,ie . Address 3-he. 'JOCK City -6 u5 Jo ,�9 Zip Code l-1;-)°,L City Zip Code 3. Name 4. Name Address Address City Zip Code City Zip Code (ATTACH ADDITIONAL CLIENT SHEETS,IF NECESSARY) State ofIrM4ga t3& 3a6"--- County of eviller 60-..i. L . ! • Sig.,_ .re This registration was sworn (or affirmed) and subscribed before me this day of Y x ,20\3 ,by vac• \ULAI► 1--M X Personally Known Blillk ,,A . -R�� l >c Produced ID DK 1 L kk/Nor 'Public Type of ID Produced k)4,st,L. Notary Public,State of New York No. 01L16098514 Qualified in Erie County R d:08/2011 Commission Expires September 15,20' Receipt# 007307877 1/14/2013 3:17:13 PM Dwight E. Brock Clerk of the Circuit Court gij- c - Customer Deputy Clerk Clerk Office Location F. JAMES MCGUIRE & JAMES BMR CASHIER Collier County Govt. Center F. DENTINGER MinutesandRecords @CollierClerk.co Building F, 4th Floor AIRPORT PULLING ORANGE m 3299 Tamiami Trail East, Suite BLOSSOM, LLC 239-252-2646 401 560 DELAWARE AVE STE 400 P.O. Box 413044 BUFFALO, NY 14202-1212 Naples, Florida 34101-3044 1 Product QUANTITY DESCRIPTION UNIT COST AMOUNT 2 BMR Lobbyist Registration $25.00 $50.00 TOTAL AMOUNT DUE $50.00 Check# 118 ($50.00) 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. ©CA UhTglil®Filhoggral Page 1 of 1