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2015/2016 Collier County Clerk of Courts Expires del 3299 Tamiami Trail E. (Cleo 's office only) Suite 401,Bldg. F, 4th Floor Naples,Florida 34112 BOARD OF COUNTY COMMISSIONERS lu LOBBYIST REGISTRATION FORM Name e-- D Q I ' Date J — 9J5 - L0 Business Name . . r1 ' ) L 4_ LL C— Business Address 'S.A..0 a Le e tt-eirPv- 3 LL, a S (P City State Zip Code 5 L--1 1 3 Li Business Telephone 023 R a 3( j1 ce ( Contact Person -e D a ( � Lobbyist E-mail h i 09 U co (-t(t 0-;'vVe--J.. 4 - .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 at Gve vs{'/( d on a-- 2. Name Address 5 ix b(o £+ A--etp,'LS-C pk-,.--Q- Address City )Qcp Ue S' Zip Code 3LI Lb 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 tit Lobbyist ►`_nature ",., y� This registration was sworn(or affirmed) and subscribed before me th} . Agy of, MOLYGVl, 20 10 , by C e Personally Known BY • ZAP t/ Produced ID Deput. 1cJerk/Nof• `Pu. i Type of ID Produced PE-- Revise..08/2011 RGI.CIFM? till VJJVVI 3/28/2016 9:40:28 AM ` ,` Dwight E. Brock Clerk of the Circuit Court -\ \O I (-' '- ^ (C )` ,� o Customer Deputy Clerk Clerk Office Location HOPE DALEY BMR CASHIER Collier County Govt. Center GUERILLA MEDIA MinutesandRecords @CollierClerk.co Building F, 4th Floor 3606 ENTERPRISE AVE m 3299 Tamiami Trail East, Suite NAPLES, FL 34104-3608 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 ($40.00) Cash Returned $15.00 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. ©000ri® a® g0Un Page 1 of 1