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2012/2013
Collier County Clerk of Courts Expires 3299 Tamiami Trail E. (Clerk' office only) Suite 401,Bldg. F,4th Floor Naples,Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name l —C 1 u.r ;.- 1 ( J of i t'1 Date 1 — It — ` Business Name ')'a \`,11 r •,) it/Cer(�h i j Inc . Business Address 2 7)50 ( )i4 (1--- City Naples State FL- Zip Code 3 [ I I Business Telephone 43L4 -0333 Contact Person Lobbyist E-mail Jdçoti in c ?j � 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 CC( ll ►'5 ia, S(' 'i.e. S dl. 2. Name Address I t 7( I C O l l ter,is 6S('v ue. Dr. Address City IL Q i'7 l e S Zip Code 31( 1 U 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 CLL J J-'-t- Lobbyist Signature Y This registration was sworn(or affirmed anc�spbscribed b this,f),:.. da o , c___hUatM , 2013 ,by re h - . Personally Known BY: ,_>: �, ,+4 _ Produced ID Ddtity'Clerk/.1*�otar,y.ublic Type of ID Produced �� 'r, , ",8, / ! ' i G v'- ,M i' evised:08/y011 Receipt# 007305686 1/4/2013 12:07:31 PM Dwight E. Brock Clerk of the Circuit Court Customer Deputy Clerk Clerk Office Location LAURA DEJOHN BMR CASHIER Collier County Govt. Center JOHNSON ENGINEERING, MinutesandRecords @CollierClerk.co Building F, 4th Floor INC. m 3299 Tamiami Trail East, Suite 2350 STANFORD CT 239-252-2646 401 NAPLES, FL 34112-4813 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. ©®1:111[1lSLJ ©hAto @C llL Page 1 of 1