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2015/2016 Collier County Clerk of Courts Expires v 3299 Tamiami Trail E. (Clerk's [lice only) Suite 401,Bldg. F,4th Floor Naples, Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name P ,E€ I w , ri. , / i ,n Date tU (13 // Business Name 13 T a I Business Address Cci t ev i el I 13 Iv ci Fort- /11 j ers F L City Fart f / ver $ State F (-- Zip Code 3 3 1 °z 0 Business Telephone'2�5 $�u~� 3 I Contact Person Lobbyist E-mail ci " I `f t 9 e 4 Ti- G G 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/F,NTITY REPRESENTED: 1. Name A Tx-I 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 County of Collier 5 Lobbyist Signature s registration was sworn(or affirmed) and subscribed before me tfrl •' I' -.day-of, I , , 20(.5 , by Personally Known =y; Vey: i, ,Ara A___,Ili )� Produced ID P-c-pc Deputy Cferk/No ry 'ublic Type of ID Produced -•vised•08/2011 INGloCINLm wrvv.»vv 10/13/2015 1:37:45 PM -,,R«,t.., Dwight E. Brock Clerk of the Circuit Court !* c'''''i'iii 6 ii.6 0 Fwg( _ _ ,eL_ °-\ c-c@c°,_ iDQ Customer Deputy Clerk Clerk Office Location DANIEL W. MULLIN BMR CASHIER Collier County Govt. Center AT&T MinutesandRecords @CollierClerk.co Building F, 4th Floor 2970 COLONIAL BLVD m 3299 Tamiami Trail East, Suite FORT MYERS, FL 33966 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. ©CD00I®T0lgg0lEra Page 1 of 1