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2011/2012 ( � %Collier County Clerk of Courts Expires {/ 3299 Tamiami Trail E. (Clerklofficeonly) Suite 401,Bldg. F,4th Floor (Clerk/ office Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name I?A( RC) Date I 3111 Business Name 12 n Vf- ;k-Fp) t2 Business Address l • I (-24V2-- Pic t 71 I O �G 90/ City � �(�--- State �''2- Zip Code Business Telephone 311( °CV Contact Person Z 11-1,00 (CA/Th r + Lobbyist E-mail t i i� r' -. -�-U 1 'S AT-1-13,1a- S.1 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 CUY'\Sc(L)?„-; •.-1() S W / Pka. Name Address 1 (-1 Sc' M L- Address City /'QL. _ ) Zip Code )"1) " - 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 Lobb st Signa e Cr vitivt This registration was sworn(or affirmed) and subscribed .- J . , 20 tt ,by Personally Known Produced ID Dept le>k o v <P . is Type of ID Produced `�� ry'4 j Revised:08/2011 Receipt# 007199648 11/3/2011 9:36:33 AM j,,,s <<,, Dwight E. Brock 1 Clerk of the Circuit Court ■ri i o o o '`` giff Customer Deputy Clerk Clerk Office Location RALF GUNARS BROOKES BMR CASHIER Collier County Govt. Center RALF BROOKES ATTORNEY MinutesandRecords @CollierClerk.co Building F, 4th Floor 1721 SE 39TH ST m 3299 Tamiami Trail East, Suite CAPE CORAL, FL 33904-5080 239-252-2646 401 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. Ig00011M3gl a ggn Page 1 of 1