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2011/2012 Collier County Clerk of Courts Expires 9 o 12- 3299 Tamiami Trail E. (Clerk's (lice only) Suite 401,Bldg. F,4th Floor Naples,Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name \ O Q-. Z `� 12 Date 50,7i, 2C-ct Z Business Name �� e4 Business Address city D fD L State °" Zip Code A-i C4 Business Telephone �?v (. 2'9 3. 3 7 3d Contact Person ��`°`' Lobbyist E-mail �� i , l%ok4t. 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 (Q,46, ) ) 2. Name Address try-, ( ,rd Address City Zip Code City Zip Code 3.Name 4.Name Address Address City Zip Code City Zip Code (ATTACH ADDITIONAL CLIENT SHEETS,IF NECESSARY) State of Florida I County of Collier Lobbyist .ignature r�61'Y ,� ' This registration was sworn(or affirmed) and subscribed before�l Cs• � ~` day of• c\tUtve— , 20 V 2--,by . , 7"- k , }. Personally Known BY. Produced ID . l rpu , lerk/I o . „ °ublic T e of ID Produced YP �r' e,;4 Revised:08/2011 Receipt#007258753 6/25/2012 11:59:13 AM L,�r<<�i .r, Dwight E. Brock Clerk of the Circuit Court ( D Vim.' ' ) P '-'7 ___qJ . __ ( ----71 '-') ---7j °it i Customer Deputy Clerk Clerk Office Location DONALD R BARBER BMR CASHIER Collier County Govt. Center SR 846 LAND TRUST MinutesandRecords @CollierClerk.co Building F, 4th Floor AGREEMENT m 3299 Tamiami Trail East, Suite 3606 ENTERPRISE AVE 239-252-2646 401 NAPLES, FL 34104-3608 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 Check#3053 ($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. ©o00nQT@IIQg®NO Page 1 of 1