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2012/2013
/ Collier County Clerk of Courts Expires 9 ` 3299 Tamiami Trail E. (Clerl{'s office only) Suite 401, Bldg. F, 4th Floor Naples, Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name C°c-A L° t T F E,/Ji; Eh9'T-- Date JA F r i Business Name 1-'040 C.,- g D IA) L O 013 y Business Address 5 0 6, R O.JI ek. f C> City A1)4 {P LC S State fit- Zip Code 3`i" 1 0 Business Telephone 39- 0207._ c r 7 % Contact Person & n e r r Lobbyist E-mail Cr IcX E y(,E AfT (1) C £Al, Notice for Lobbyists: The annual registration fee is$25.00 per Lobbyist, per Collier County Ordinance No. 2003-53, and amended by Ordinance 2004-05 and Ordinance 2007-24. Payments made out to: Collier County Clerk of Courts or Dwight E. Brock, Clerk of Courts (ADDRESS LISTED ABOVE) NAME AND ADDRESS OF EACH CLIENT/ENTITY REPRESENTED: 1. Name P1 A 60©u A p4rJ P / 6t-!>fr4( Name Address ]( 'i 7 S A t pf2-$ /- i:t Address City e/0 A P4-61S- Zip Code 3 Y/D a City F L 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 �� - f — A ;r Lobby st Signature This registration was sworn(or affirmed) and subscribed bef me this 'day of, , 20 13 , by f y, Personally Known BY: "u Produced ID Deputy Clerk/Notary Public Type of ID Produced Revised.08/2011 Receipt# 007329129 4/5/2013 9:15:07 AM t,, Dwight E. Brock Clerk of the Circuit Court r7yn i7}zt — I Customer Deputy Clerk Clerk Office Location GARRETT FX BEYRENT BMR CASHIER Collier County Govt. Center LONG BOW LOBBY MinutesandRecords @CollierClerk.co Building F, 4th Floor 506 GORDONIA RD m 3299 Tamiami Trail East, Suite NAPLES, FL 34108-2631 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 ($100.00) Cash Returned $75.00 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. ©©UUU®E ©U®E ft ©O nI Page 1 of 1