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2012/2013
Collier County Clerk of Courts Expires l !o1; 3299 Tamiami Trail E. (Clerk's ice only) Suite 401, Bldg. F, 4th Floor Naples, Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM ? l Name �� S Al �� Date C`'C)c- Business Name -\.4t, -c?fSc� c Ch14\�' ) G(��5�4 \� Ievicf'a-k_ Business Address `i tj ? { 6 N\k City \ -r 5 State Zip Code 3 3 ta� Business Telephone Z—Vk \ftt Contact Person V\tkr S' is‘sAA Lobbyist E-mail ma r\ S AI- V A \\AN' C6 n'1 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 2. Name f Address"kl5 L\i 0 - J Address °15 O t - 1\11 . ate City r, City --(S Zip Code3ctUb City W0,11\4_ Zip Code 3 ! 1. 0 3. Name`--- U 1 Y \ 54\1 \ 4. Name Address " 1 \ S�i Address City Zip Code 6 1 City Zip Code (ATTACH ADDITION L C LENT SHEETS,IF NECESSARY) State of Florida County of Collier A obby GTh's registration was sworn(or affirm d). d subscribed before me day of _ 20 by L- 1 Personally Known BY: 1/1)\11 - ‘Ar-0/.%t"'- Produced ID Deputy Clerk/Notary Public Type of ID Produced �L �- Revised:08,20'11 Receipt# 007287861 10/23/2012 2:47:30 PM ;9t2Yd.4 Dwight E. Brock Clerk of the Circuit Court 3 4 ,1 >> gggcc=i — o Customer Deputy Clerk Clerk Office Location MARK SCHULTZ BMR CASHIER Collier County Govt. Center HENDERSON, FRANKLIN, MinutesandRecords @CollierClerk.co Building F, 4th Floor STARNES & HOLT, P.A. 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 Cash Tendered ($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. ©CA rigT©pgliaKoggpThl Page 1 of 1