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2014/2015 Collier County Clerk of Courts ExpiresU 1 Q 26 15 3299 Tamiami Trail E. (Clerk's ffice only) Suite 401,Bldg. F,46 Floor Naples,Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBB T REGISTRATION FORM Name --4�(n oreiJl Date I 20 Business Name ` a: tL,a Lrvado , P4 • Business Address ?)2-on y i com i t Y CU I City Nay State Zip Code J Business TelephonenQ" tiOlt `r e7SCS Contact Person h ow • Y' • Lobbyist E-mail c,t G U2 C 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 DW/9 0r 2. Name Address,-5,z9 ,/O1,,' /oi:6 Address City fi{�L 5' Zip Code�/�/2 City Zip Code 3. Name 4.Name Address Address City Zip Code City Zip Code (ATTACH ADDITIONAL CLIENT SHEETS,IF NECESSARY) State of Florida 40111 County of Collier r Iyi'ifrSignature his registration was sworn(or affirmed) an. e• ribed before me this 2 day.of , 20 \S, by —.. I Personally Known BY: Produced ID Deputy'Cler otary P bli Type of ID Produced - Vlsed:08/2011 I�CliC1�.J eft VV/JJLV"P 4/28/2015 10:56:33 AM Dwight E. Brock y.. Clerk of the Circuit Court n n _15 " ri } yj Customer Deputy Clerk Clerk Office Location ANTHONY P. PIRES, JR. BMR CASHIER Collier County Govt. Center WOODWARD, PIRES & MinutesandRecords @CollierClerk.co Building F, 4th Floor LOMBARDO, P.A. m 3299 Tamiami Trail East, Suite 3200 TAMIAMI TRL N STE 200 239-252-2646 401 NAPLES, FL 34103-4108 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. ©©U00® @ D @® 11 1J Page 1 of 1