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2013/2014 Collier County Clerk of Courts - Expires tI&L 4 3299 Tamiami Trail E. (Clerk's office only) Suite 401, Bldg. F, 4`h Floor Naples, Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name 2 r.a..d )P y Co r n e Date 1(2/1k /13 Business Name Cc )1 eY- Co v / )vt h So c c y/ -,1 v Flfr J►Business Address /0 ,Z 0 ., e , S S4e -1— City ,i e State L Zip Code 3 c f j u Business Telephone ,)37 - 't/ 3 -74=�L Contact Person s,C t--2— Lobbyist E-mail be c, melt l;' c e, [ t i e r 2 v ctv 'rl 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: p I. Name G r ,,� v� � Name v v ���� � // Address S a w.e Ct J Ct , i Address L)a L1 Y u c k Ji A V e, e € 0 City Zip Code City M 00^^^^ FL Zip Code 3 3 f / 3. Name 4.Name Address Address City Zip Code City Zip Code (ATTACH ADDITIONAL CLIENT SHEETS,IF NECESSARY) State of Florida , . of Collier / � G t?^ Lobbyist Signaturre) pp u • n • Thi registration was sworn r affirmed) and subscribed before me this day of, 1-1 D , 20 ! , byQ) - ,; • ..,.•• • Personally Known BY: Ot,(,t, � C Produced ID Depu — otary Public Type of ID Produced Revised:08/2011 Receipt#007387499 10/18/2013 2:53:26 PM <!, 1 Dwight E. Brock Clerk of the Circuit Court ���� � � (� _ Customer Deputy Clerk Clerk Office Location BRAD CORNELL BMR CASHIER Collier County Govt. Center COLLIER COUNTY MinutesandRecords @CollierClerk.co Building F, 4th Floor AUDUBON SOCIETY m 3299 Tamiami Trail East, Suite 1020 8TH AVE S STE 2 239-252-2646 401 NAPLES, FL 34102-6959 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#2655 ($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. ©®[EW©ILI®lfZciggEfa Page 1 of 1