2012/2013 Collier County Clerk of Courts Expires 17201-3
3299 Tamiami Trail E. (Cle ffice only)
Suite 401,Bldg. F,4th Floor
Naples,Florida 34112
BOARD OF COUNTY COMMISSIONERS
LOBBYIST REGISTRATION FORM
Name IA‘C \C.1 V . 4, ,Q trk Date 61111 i
Business Name Gfta.±1_NI( tV 11,0 6 C (J WY}m f(Q
Business Address 2 '?i1D Tamar .,� i Tm L i 1�1 No SUJr
,L
City �S State l� Zip Code 3 -j I O
Business Telephone 2 , 403 ; 2 01 Contact Person
Lobbyist E-mail 1(\(\\ ,.. C `Q�\ C sjy\bC.11 4 0 F'
Notice for Lobbyists: The annual registration fee is 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. NameT .-bOtt tC NCk S Ch n 0 2. Name ' /1 4 t / • t&\ it
Address 2.-41 0TOAthm t ;(0:At N vat% Z Address 2._3(10 �, .11�".:N. (F.. ' 2-1 Q
City \V4St,S Zip Code 39103 City N 4 .% Zip Code 34 IN
3. Name 4. Name
Address Address
City Zip Code City Zip Code
(ATTACH ADDITIONAL CLIENT SHEETS,IF NECESSARY)
. . . . . . . . . . . . .
State of Florida
40119 .4111
County of Collier , /
Lobbyist Signature
T 's re istration was sworn r affirmed) d ubscribed before me this 4776°
day of,
, 20 / -, by A
t-Personally Known BY: AeeAte, /
Produced Ia - r.7'*' : k/N•tar`'ublic
Type of ID Produr = MARY A. OXLEY /
057028
EXPIRES February 08,2015 Revised:0812011
(407)3980153 FbridallotaryService.com
Receipt# 007283399
10/4/2012 2:13:24 PM
,,,_,>;T Dwight E. Brock
, Clerk of the Circuit Court
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Customer Deputy Clerk Clerk Office Location
MICHAEL V. REAGEN BMR CASHIER Collier County Govt. Center
THE GREATER NAPLES MinutesandRecords @CollierClerk.co Building F, 4th Floor
CHAMBER OF COMMERCE m 3299 Tamiami Trail East, Suite
2390 TAMIAMI TRL N STE 210 239-252-2646 401
NAPLES, FL 34103-4484 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# 28323 ($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.
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