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2012/2013
Collier County Clerk of Courts Expires V2-01 3299 Tamiami Trail E. (Clefice only) Suite 401,Bldg. F,4th Floor Naples,Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name J ` M t3 6 A/JI4S Date .S" )L) - Z o13 Business Name 3 M J 4A-Ns P° (TAT) 0 I i /v a s 1 N e k 2 i N 7/tic Business Address -G J 2 St i N w City N Ps PL S State F Zip Code 321 2-D Business Telephone Z3/- / 1 1 - 2767 Contact Person Lobbyist E-mail j6/0:7,S w -t e "SA). C 0/11 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:p 1.Name IA/Ot /! ALEILThp el 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 44• st "ignature 's registration was sworn(or affirmed) and subscribed before my`tIis "`day of, , 20 !3, by .•^ Y // f ./ 4 Personally Known BY: :y• Produced ID / Deput}p'CIeileNotai'P • Type of ID Produced � 0• - -. .8/2011 Receipt# 007340297 5/14/2013 1:29:51 PM /�11tc Ue,,,J, Dwight E. Brock ,� Clerk of the Circuit Court 1 1:f‘;\ ‘'\. .,._-','''',4-.kii,:j.'›V 0 ,ffET „2,_, -\ \ ° , , c-D7° RR Customer Deputy Clerk Clerk Office Location JAMES M. BANKS BMR CASHIER Collier County Govt. Center JMB TRANSPORTATION MinutesandRecords @CollierClerk.co Building F, 4th Floor ENGINEERING, INC. m 3299 Tamiami Trail East, Suite 761 21ST ST NW 239-252-2646 401 NAPLES, FL 34120-1813 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#2168 ($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. ©CQQOQQ® @Q (j] Page 1 of 1