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2011/2012 Collier County Clerk of Courts Expires //G201 3299 Tamiami Trail E. (Clerk's office only) Suite 401, Bldg. F, 4th Floor Naples, Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name p u r 4(ct4 Date .:V)6/( Z Business Name Pw I �x Business Address i S. &r�(.e`c City naico is/MC State L Zi p Code 31111-4 C Business Telephone 2336/ 3.37 1 Contact Person V4,...);(■ n✓&14/I Lobbyist E-mail j,,A., 01\ 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 /Liat_.€do Isjegip 0,,,,,,cr n-p 2. Name C'd 1,4I4-eiee eo Address . /Co a qJ , 00- L11`e,� RLaC1 Address City pa TsL'b,/-LZip Code 3V'i/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 10/ County of Collier / I b i s4 ' nature This registration was sworn (or affirmed) and subscribed before me this /‘ft"' day of, re4tvaal, 20 I'Z , by k jsti rI / Personally Known BY: Produced IDS MONTE LAZARUS D - , i tary Public Type of ID Produced :;p. '; • #DD894772 •�' EXPIRES June 01,2013 F'lcrideNotIr SAry'ce'Com Revised: 08/2011 (407).38:0.:53 Receipt# 007224705 2/22/2012 9:33:23 AM Dwight E. Brock Clerk of the Circuit Court \k'4'1 ti ffggc- 0 Customer Deputy Clerk Clerk Office Location ALAN BROWN (ISLAND BMR CASHIER Collier County Govt. Center GARDENERS, INC.) KEVIN MinutesandRecords @CollierClerk.co Building F, 4th Floor DONLAN (PUBLIX) RICHARD m 3299 Tamiami Trail East, Suite S. SHANAHAN (RICHARD 239-252-2646 401 SHANAHAN, I P.O. Box 413044 MARCO ISLAND AREA Naples, Florida 34101-3044 CHAMBER OF COMMERCE 1102 N COLLIER BLVD MARCO ISLAND, FL 34145- 2547 1 Product QUANTITY DESCRIPTION UNIT COST AMOUNT 3 BMR Lobbyist Registration $25.00 $75.00 TOTAL AMOUNT DUE $75.00 Check# 7305 ($75.00) 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. ggfillincgiTgil®ITEZoggIDO Page 1 of 1