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2011/2012 'Collier County Clerk of Courts Expires 71=9-6/)--- 3299 Tamiami Trail E. (Cie ffice only) Suite 401,Bldg. F, 4th Floor Naples,Florida 34112 BOARD OF COUNTY COMMISSIONERS nn LOBBYIST REGISTRATION FORM Name /111/2A .JOF/A) Date /0//4/// Business Name JO/-//J6OAJ �/l�6%/JE-Ei�/��'� /�✓� Business Address 2 35-0 7",4 Coo 7' City Ai/2791--E. State FL- Zip Code 3482- Business Telephone -534-0046, Contact Person Lobbyist E-mail /do oh/7C f ohi SOf)�J91 GYI o' 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 2. Name Address Address City Zip Code 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 1 Lobbyist Signature This registration was sworn(or affirmed) and subscribed before me this I‘t TN day of, cr. , 20 1 l , by L../44.,,e44- b is rho/ k/ Personally Known BY: Produced ID Dep Clerk/N ary Public Type of ID Produced 40071:44, JENNIFER LYN CHAPMAN s i1` Notary Public-State of Florida Revised:08/2011 ii (•My Comm.Expires Sep 14,2014 Commission#EE 16176 ���kitrow Bonded Through National Notary Assn. Receipt# 007195603 10/17/2011 3:30:43 PM Dwight E. Brock Clerk of the Circuit Court `' ti -7 Le p 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 Check# 18451 ($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. ©®0011® O® gg ![L Page 1 of 1 N. . 0 N N CO in st V co M co 0 M M 0 cO J J J LL u) LL M 0 LL Li_ M N O a) l6 N LL a) ..4- 0. a co C p,M N N O J CO O N of Z CD LL a) Z LL 0 a) ° M ui 0 > O N > z J N 0, >Q Q ca z N M 0 CO sr co CO CO CL J N 0 N00 JMM 0 CD ca LL 0 a) N a) I Z LL CO CO N t 3 . LL M v co Z ~ a) C co co CO CO 0 m Z O ` 0 M - r C. •7 CO w a) aj 0 co 0 U N IC) N V. 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