2012/2013Collier County Clerk of Courts
3299 Tamiami Trail E.
Suite 401, Bldg. F, 4`h Floor
Naples, Florida 34112
Expires 61— 30 —a0 10
(Clerk's office only)
BOARD OF COUNTY COMMISSIONERS
LOBBYIST REGISTRATION FORM
141 rP� d4kM_rD � Name Date
Business Name
Business Address 500 /L.:✓Y LOA) .
City INApar- State
StU`� ID
Zip Code
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Business Telephone 239 ��� ' �P lZ Contact Person ZO
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Lobbyist E -mail
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
� CLIENVENTITY REPRESENTED:
1. Name&W �EI�. & D � i �D• 464 2. Name
'
Address 3 200 & Il n
City 4bS 6- Zip Code 3�i /Ds
Address
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
Lobbyist Signature ���� ••......,• ,
V-
21 registration was sworn (or affirmed an subscribed before me. this ` of
Personally Known BY: d
-/--Produced ID / // Deputy
Type of ID Produced
�e
J.Revtsed: 09/201,
Dwight E. Brock
Clerk of the Circuit Court
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21 r7tF #fit L PO
Customer
KATHLEEN CURATOLO
CBIA
3200 BAILEY LN STE 110
NAPLES, FL 34105 -8524
1 Product
Receipt# 007313848
2/712013 12:10:21 PM
Deputy Clerk Clerk Office Location
BMR CASHIER Collier County Govt. Center
MinutesandRecords @CollierClerk.co Building F, 4th Floor
m 3299 Tamiami Trail East, Suite
239 - 252 -2646 401
P.O. Box 413044
Naples, Florida 34101 -3044
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.
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