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2012/2013
Collier County Clerk of Courts Expires 3299 Tamiami Trail E. (Clerk's o ice only) Suite 401, Bldg. F,4th Floor Naples,Florida 34112 BOARD OF COUNTY COMMISSIONERS �� LOBBYIST REGISTRATION FORM Nam� ��(LY—A' it 4-i 0 /1l i.(.6-i:�-�7, Date 342((3 Business Name ' 7 /, 1/14- Business Address I/7z., /4- City'Aieeee State Zip Code 5 /4-(01-1-- Business TelephoneN-44 Contact Person (L,t-mot 1 - Lobbyist E-mail timeAL (2-?1,4 Q T c,4 . Cam" 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 gip.f r-074.06 t1e--,f- 2. Name Address(1M ,J- -4042/7-12e Address City /ti„ 4.6 , Zip Code3407%% City Zip Code 3. Name 4. Name Address Address City Zip Code C' Zip Code (ATTACH ADDITIONAL CLIENT SHEETS,IF NECESSARY) State of Florida County of Collier / 4‘/M Lobbyist Signature is re i tration was sworn(or affirmed) and subscribed before 'e this AL day of, , 20 ('),by . Personally Known Produced ID Deputy Clerk/Notary Public EA. T e of ID Produced t - (../L ( - Revised:0812011 Receipt# 007322165 3/12/2013 1:03:17 PM Dwight E. Brock Clerk of the Circuit Court cii0/ gif ' ED) Customer Deputy Clerk Clerk Office Location REMIGIO MENDOZZI 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 Deposit Account#: D-03450 ($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. ©OD AMSLJ US ❑@OC n Page 1 of 1