2016/2017 Collier County Clerk of Courts Expires 0q0(2()(7
3299 Tamiami Trail E. (Clerk's ice only)
Suite 401,Bldg. F,4th Floor
Naples,Florida 34112
BOARD OF COUNTY COMMISSIONERS
LOBBYIST REGISTRATION FORM
Name i-4S d. 1"k • 7...,r)o .. Date \ 14‘ I (7
Business Name NA.pu s PO'c... B o..— 0 c P.e.Ak0 r$
Business Address 14 q-5.- P:�- ,4-z)52._ 'co.-
City N a Pti-s State PL CZip Code 3 y (°et
Business Telephone 7 31- S9 7- 11/5 7 Contact Person £0 J'1.r 1•� k o
Lobbyist E-mail -3eSSe e_ p a 6o r . co M
Notice for Lobbyists:. The annual registration fee is$25.00 Der 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 OIV4(- 2. Name
Address IH s 5' •)N I- :ay at.. Address
City 14A6U5 Zip Code 3M IOR City Zip Code
3. Name 4.Name
Address Address
City Zip Code City Zip Code
(ATTACH ADDITIONAL CLIENT SHEETS,IF NECESSARY)
State of Florida4Il /
County of Collier /�i
Lobbyist i gnature
g � 94-
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day of,
Is registration was sworn firmed and-sybsc 'bed before me this
a't_,� , 20/ , by 5S n 1 . /- lu' /r r1 .
t,�Personally Known cRi NSE 'I(( Cs EkiA SC
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Produced ID �o °�f;=; Notary Public-State o`(Fiorib� uty Cler otary Pul�h
Type of ID Produced { ; My Comm.Expires Sep 20,2017 �
-,,E'�`�` Commission #FF 038437
%:.•"' Bonded Through National Notary Assn. 0 Revised:08/2011
Receipt# 007754589
1/23/2017 4:11:05 PM
;FKfc;tii Dwight E. Brock
Clerk of the Circuit Court
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Customer Deputy Clerk Clerk Office Location
JESSE M. PURDON BMR CASHIER Collier County Govt. Center
NAPLES AREA BOARD OF MinutesandRecords@CollierClerk.co Building F, 4th Floor
REALTORS m 3299 Tamiami Trail East, Suite
1455 PINE RIDGE RD 239-252-2646 401
NAPLES, FL 34109-2139 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
Check# 028228 ($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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