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2016/2017 Clerk to the Board,Minutes&Records Dept. Expires CCA L" b 3299 Tamiami Trail East, Suite#401 (Staff use only) Building F,4th Floor Naples,FL 34112 BOARD OF COUNTY COMMISSIONERS oLOB/B, t' LOBBYIST REGISTRATION FORM (d) NameQ ( (Sh SC c7 i Date S f' /9— Business ' /9—Business Address 1495 Smith Preserve Way Naples FL 34102 Business Telephone E-Mail NAME AND ADDRESS OF EACH PERSON OR ENTITY REPRESENTED: 1). Conservancy of Southwest Florida 1495 Smith Preserve Way _ Naples FL 34102 N o N Q0 > c4N 2). Eay A . F- U . C Z tt!W N a U. N aa.>. E E M . U U z (PLEASE ATTACH ADDITIONAL SHEETS,IF NECESSARY) ".o,, :� 'fit i6 s ?412 .,H • cAF. Lobbyist Signature State of Florida County of Collier 9 0 N . Ng• i N n The foregoing registration was sworn to and subscribed before me on this ( s' day of VI 0,1 tzety ,by gliSen la;eseeft. , who isper_gonallyknown to me or has produced as identification and who did take an oath. BY: he1 c. CC,_._ 41 c Deputy Clerk/Notary Public The annual registration fee is$25.00 per Lobbyist,according to Collier County "•.,,;,'� Ordinance No.o.2003-53,as amended by Ordinance 2004-05,Ordinance 2007-2 - - - - and Ordinance 2013-39. Please make payment to: Collier County Clerk of Courts or Dwight E.Brock,Clerk of Courts and mail to the address listed at the top of the form. Receipt# 007781528 4/11/2017 8:16:43 AM Dwight E. Brock Clerk of the Circuit Court o -i o CO) SII! R�4.. _�J I� / _:;7 �� - pt Customer Deputy Clerk Clerk Office Location ALISON D. WESCOTT BMR CASHIER Collier County Govt. Center CONSERVANCE OF MinutesandRecords@CollierClerk.co Building F, 4th Floor SOUTHWEST FLORIDA m 3299 Tamiami Trail East, Suite 1495 SMITH PRESERVE WAY 239-252-2646 401 NAPLES , FL 34102 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# 17814 ($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. ©CAUM®T©ll®TihogOED Page 1 of 1