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2012/2013 Collier County Clerk of Courts Expires !� 3 3299 Tamiami Trail E. (C rk's office only) Suite 401, Bldg. F, 4th Floor Naples, Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name uaVIGl R . Ur 1erhit i ,Jr. Date 1011 I Z Business Name 3' cIX ICS 01111'1e-ell r10 Business Address 1 D I I Si u IVY 12 C\j p vess P4k-vkAA1 GA &wit 1 0 ( City Ft .Myers State F(- Zip Code 9tato Business Telephone 401O Contact Person Lobbyist E-mail 01 nclerh%U !IxaniiSen9 •&Om Notice for Lobbyists: The annual registration fee is 525.00 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 Address Address City Zip Code City Zip Code 3. Name 4. Name Address Address City Zip Code City Zip Code (ATTACH ADDITIONAL CLIENT SHEETS,IF NECESSARY) State of Florida Olei It/ County of Collier Lobbyist Signature This registration was sworn (or affirmed) and subscrib d before me this ( day of, WOW, 20 .. , by i1M�U e.W1(1041(1) ■ 1' Personally Known BY Y GL"e-ORKIIU Produced ID . D pV uty Clerk/Notary Public Type of ID Produced ' •M.SHEPPARD *; ! :`,r; MY COMMISSION#DD 908267 1S1„#,:....:41,4: EXPIRES:November 16,2013 Revised:08/2011 .,Rf,th�'' Bonded Thru Notary Pubic Underwriters Receipt# 007283398 10/4/2012 2:11:29 PM , r1�z ,R,TJ Dwight E. Brock Clerk of the Circuit Court (c)9ffffill— — i] < C/7 i71 FrHC=-ryc Customer Deputy Clerk Clerk Office Location DAVID R. UNDERHILL, JR. BMR CASHIER Collier County Govt. Center BANKS ENGINEERING MinutesandRecords @CollierClerk.co Building F, 4th Floor 10511 BEN/6 MILE PKWY m 3299 Tamiami Trail East, Suite UNIT 101 239-252-2646 401 FORT MYERS, FL 33966-6511 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# 19143 ($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. ©CQ_OQTIJ ❑ggplfa Page 1 of 1