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2012/2013
Collier County Clerk of Courts Expires 2 3299 Tamiami Trail E. erk's orre.only) Suite 401, Bldg. F,4th Floor Naples,Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name ('/Sf'« /`7. /4U7i-ea lc r-li,-, z Date 3// 2 Business Name Business Address /2 2 /1/ ,4r � � ,ea/ City /I'7lef State Zip Code Business Telephone Z3 9-y/7-7z z Z Contact Person -e/574 i /2c.v 7‘fit c z Lobbyist E-mail q/vf74%, o --f , cc' 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 74e7 /Va7y.5 LGC 2. Name Address / 7/ Address City a, �'P" Zip Code 975V City Zip Code 3. Name 4. Name Address Address City Zip Code City Zip Code (ATTACH ADDITIONAL CLIENT SHEETS,IF NECESSARY) State of Florida County of Collier Lobbyi0.'_ ature f.'6( This regis ation w s sworn(or affirmed) and subscribed before me this v day of, 0 ( y Personally Known 95-ktV4 Z--Produced ID Deputy Clerk/Notary Public . Type of ID Produced Revised:08/2011 Receipt# 007322166 3/12/2013 1:06:09 PM ;,*<<)t, Dwight E. Brock Clerk of the Circuit Court in z: 0 ©ffff a— � — a— - \C-' 4 aa — EDER Customer Deputy Clerk Clerk Office Location DUSTIN RAUTENKRANZ BMR CASHIER Collier County Govt. Center TAMIAMI HYUNDAI MinutesandRecords @CollierClerk.co Building F, 4th Floor 1229 N AIRPORT ROAD m 3299 Tamiami Trail East, Suite NAPLES, FL 34104 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 ($17.10) Deposit Account#: D-03450 ($7.90) 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. V00[1 11QOQ ❑ggn Page 1 of 1