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2011/2012
Collier County Clerk of Courts 3299 Tamiami Trail E. Suite 401, Bldg. F, 4th Floor Naples, Florida 34112 Expires 69 �,6 (Clerk's Ace only) BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name &Eat �. _i 2\ 1 Date Business Name 12 n LS" 47WOlO' 427 P, L Business Address// 33(6 / -3o N I T4 6epoff-F 0D , 51 e . Su/ 7�c`/D City WdiT,_4 State 'CL Zip Code 5zll :3j Business Telephone,-23'�T- %77- 7V/Contact Person 92F 'e, J;�-4 / Lobbyist E -mail 11-7 3 q � c< ©,I«s 1- N, Notice for Lobbyists: The annual registration fee is $25.00 per Lobbyiat, 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 CLIENUENTITY REPRESENTED: 1. Name jra0 LL lE_& 2• Name Address a d two Gel -)E= %G�t� Address �t- /vv City Zip Code City 3. Name 4. Name Address Address City Zip Code City (ATTACH ADDITIONAL CLIENT SHEETS, IF NECESSARY) State of Florida County of Collier Zip Code Zip Code ire istration was sworn (or affirmed) and subscribed before me •thig ° • • m day of, 20_LL, by � ✓ 1 �__rod rs onally Known gr r uced ID \ < Deputy C1erQNot ry Public Type of ID Produced Uf • t C - Revised: 08/2011 Receipt# 007209420 12/15/2011 8:31:33 AM Dwight E. Brock -- Clerk of the Circuit Court F (T�� SQ( "�T) Customer Deputy Clerk Clerk Office Location REED JARVI BMR CASHIER Collier County Govt. Center OMEGA CONSULTING MinutesandRecords @CollierClerk.co Building F, 4th Floor GROUP, LLC m 3299 Tamiami Trail East, Suite 11338 BONITA BEACH RD SE 239 - 252 -2646 401 BONITA SPRINGS, FL 34135- P.O. Box 413044 5932 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# 1714 ($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. Page 1 of 1