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2015/2016 Collier County Clerk of Courts Expires 3299 Tamiami Trail E. (Clerk s office only) Suite 401,Bldg. F,4th Floor Naples,Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM, Name , ./ �Le ( Date /0//,3//r k �) I Business Name c5' r_ 711 0(k Sfr fe Business Address 7 /0 ( J G o / Ir / "lr r l v c- City .5-t;PV C( ly State -i--A Zip Code 5101 Business Telephone 7 t 2 — Z 2 4- Sad Contact Person Lobbyist E-mail kJiv\dal\ ESa,ke 1114104' , CE" 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 SCd9 rt. I '1 WS-fr lee 2. Name Address 1 1 di& iW i D` . Address City J`(a v L-- —2-1 Zip Code 5 ) , 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 Lobb Signature '. ) .. Th. registration was sworn(or affirmed) and subscribed befor rfi this��` day of, 20 L 5, by z:r �) •+ Personally Known BY •f A. K Produced ID t Qom-- I3,eputy Clerk/N• . ' blic ryb i ' -t Type of ID Produced � , . . ed:08/2011 RGbCI1JIf• VV/VVJUU.P 10/13/2015 1:40:23 PM Dwight E. Brock Clerk of the Circuit Court cig 0 qg 0 Ea Customer Deputy Clerk Clerk Office Location KEITH TINDALL BMR CASHIER Collier County Govt. Center SABRE INDUSTRIES MinutesandRecords @CollierClerk.co Building F, 4th Floor 7101 SOUTHBRIDGE DR m 3299 Tamiami Trail East, Suite SIOUX CITY, IA 51111-1000 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. ©CADIU '@QgTaKog ] Page 1 of 1