2011/2012
Collier County Clerk of Courts
3299 Tamiami Trail E.
Suite 401, Bldg. F, 4th Floor
Naples, Florida 34112
Expires
BOARD OF COUNTY COMMISSIONERS
LOBBYIST REGISTRATION FORM
Name ~\G~l\ ~ ;~~ Date
Business Name _ _L t7 ~~~~ - _'~ ~ C h (Ui\ber 0+ C A) l\\ Y'I\ilJf UL
Business Address 1')Cj D 'I (\1'(\\ (;J'{\ \ T \1\.U N 0 {\--~ I 'S. U A +~ 11 D
City Nl\V\ Q S State r L . Zip Code 3 Lf~ 0 ,~
Business Telepho~e ~ C(o~ -;)9lJ ( Contact Person
Lobbyist E-mail \(\i\(~C6JVle.\..pl ~ ;) C}'\(U'I\ b~ r -. - 0 r~
Notice for Lobbvists: The annual registration fee is $25.00 oer Lobbvis , per Collier County
Ordinance No. 2003-53, and amended by Ordinance 2004-05 and Ordinance 2007-24.
Payments made out to: Collier Countv Clerk of Courts or Dwight E. Brock, Clerk of Courts
(ADDRESS LISTED ABOVE)
NAME AND ADDRESS OF EACH CLIENT/ENTITY REPRESENTED:
Ii . ( t ~(ct I "''' ~ ^,' l' C .
I. Name \\\.3.... b(~ctl-e( ~QS t~(J.-P.1Q( ()1 tI 2. Name LK~S uf -a{ UkJ:~h~1 Y\,c.. I
Address 2-3qQ \Cit)1t(U1,,',1i1A'd N) ~ie. 'lJ 0 Address2...~~ () lOmlO k0J TV-cuI1j,L, ~-Ie JI D
City ~LR S Zip Code~ City~(Q\ Zip Code 3lf 103
3. Name
4. Name-
Address
Address
City Zip Code
(ATTACH ADDITIONAL CLIENT SHEETS. IF NECESSARY)
City
Zip Code
Lobbyist Signature .
V Personally Known
Produced ID
Type of ID Produced
/ ~-iA_ day of,
1JljS registration was sworn (or affirmed
U,(l-;L , 2olL, by .
,,;iT:'y:~~~, MARY A. OXLEY
~., '>f{
~.:' ".:: MY COMMISSION # EE057028
:, .~ : : February 08, 2015
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(407) 398-0153 FloridaNotaryService.com
-Dep~YClerklN otar~Ublic
Revised: 08/2011
Receipt# 007199027
11/1/2011 11 :23:25 AM
Dwight E. Brock
Clerk of the Circuit Court
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Customer Deputv Clerk
MIKE V. REAGAN BMR CASHIER
THE GREATER NAPLES MinutesandRecords@CollierClerk.co
CHAMBER OF COMMERCE m
2390 TAMIAMI TRL N STE 210 239-252-2646
NAPLES, FL 34103-4484
Clerk Office Location
Collier County Govt. Center
Building F, 4th Floor
3299 Tamiami Trail East, Suite
401
P.O. Box 413044
Naples, Florida 34101-3044
1 Product
QUANTITY
1
DESCRIPTION
BMR Lobbyist Registration
UNIT COST
$25.00
TOTAL AMOUNT DUE
Check# 27681
BALANCE DUE
AMOUNT
$25.00
$25.00
($25.00)
$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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