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2012/2013 Board Minutes & Records Expires: I L��� 3301 Tamiami Trail East Building F, 4th Floor Naples, FL 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name: ' au'it 1-.. /.e_tzla ICr< Date: /0/,0 a Business Address: /s-16 6e cI/e e 7 ' • /Vicep%es, Ft 34/0.1 Business Telephone: q•a(oa-57/09 X (0 7 Email: dad , e.) /eS zdo.drq NAME AND ADDRESS OF EACH PERSON OR ENTITY REPRESENTED: /VcyleS Goo •12,-1 C PLEASE ATTACH ADDITIONAL SHEETS IF NECESSARY P / Lo byist Si re State of Florida County of Collier The foregoing registration was sworn to and subscribed before me on this e.2( - day of Oth.6e{, c20/a, , by ca u,i_ L /e_ fz/a Fr , who is personally known to me or has produced as identification and who did take an oath. Z.RYAS CAMILLE PICKENS /] No soy, NOTARY PUBLIC BY: � L C�/, _ —°Y��o STATE OF FLORIDA ��vY �� a Comm#EE145095 Deputy Clerk/Notary Public SINCE IV Expires 1/3/2016 The annual registration fee is $25.00 per Lobbyist, according to Collier county Ordinance No. 2003-53,as amended by Ordinance 2004-05 and Ordinance 2007-24. Please make payment and mail to:Collier County Clerk of Courts or Dwight E. Brock, clerk of Courts (at the address listed at the top of the form). Receipt# 007284000 10/8/2012 1:35:38 PM Dwight E. Brock Clerk of the Circuit Court 0 ffgg _ -b-yR Customer Deputy Clerk Clerk Office Location DAVID TETZLAFF BMR CASHIER Collier County Govt. Center NAPLES ZOO MinutesandRecords @CollierClerk.co Building F, 4th Floor m 3299 Tamiami Trail East, Suite 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 Check# 16849 ($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. ©CAli ° 0(g ❑g0 L( (1 Page 1 of 1