2011/2012
Collier County Clerk of Courts
3299 Tamiami Trail E.
Suite 401, Bldg. F, 4th Floor
Naples, Florida 34112
Expires
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(CIe 's office only)
BOARD OF COUNTY COMMISSIONERS
LOBBYIST REGISTRATION FORM
Name 'D(L'k,~/1 1-1. eA Date /()r/l- Z/)/ /
BUSineSSNameU;(^~\\01, N ~~ PA A/;;m1el" I faAA )
Business Address fV ~~ t< J-fA ~
City f!oJ(\'6 )o€-A Le State ~ L
Business Telephone . 6{} -' '.-; J ,-- -:--1 Contact Person
Notice for Lobbvists: The annual reg stration fee is $25.00 per Lobbvist, per Collier County
Ordinance No. 2003-53, and amended by Ordinance 2004-05 and Ordinance 2007-24'-
Payments made out to: Collier County Clerk of Courts or Dwieht E. Brock. Clerk of Courts
(ADDRESS LISTED ABOVE)
Zip Code '~Z;Z L-
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Lobbyist E-mail
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NAME AND ADDRESS OF EACH CLIENT/ENTITY REPRESENTED:
I. Name~.Jl Elc!l1/J( Jib 2. Name
Address 'S'~ V ~ (0 t ~'UL -\- Address
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City R: My >'-/3 Zip Code !r3CT(/)S "City
Zip Code
3. Name 4. Name
Address Address
City Zip Code Zip Code
(ATTACH ADDITIONAL CLIENT SHEETS, IF NECESSARY)
State of Florida
County of Collier
....-;r.~.r;;,"'" CRYSTAL ILLE DER
f"l':"/A~\ MY COMMISSION # EE 001809
~( .~~ EXPIRES: June 2, 2013 .
'~~;;r",~$ Bonded Thru Notary Public Underwnters
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This registration was sworn (or affirmed) and subscribed before me this
QrJ-obcI , 20-LL, by OCUt'\ie \ \--t. C 0)<.. .
~Personally Known BY:
Produced ID
Type ofID Produced
otary Public
Receipt# 007199025
11/1/201111:19:27 AM
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Dwight E. Brock
Clerk of the Circuit Court
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Customer
DAN H. COX, P.A.
PO BOX CC
CARRABELLE, FL 32322-1229
Deputv Clerk
BMR CASHIER
Min utesand Records@CollierClerk.co
m
239-252-2646
Clerk Office Location
Collier County Govt. Center
Building F ,4th Floor
3299 Tamiami Trail East, Suite
401
P.O. Box 413044
Naples, Florida 34101-3044
1 Product
QUANTITY
1
DESCRIPTION
BMR Lobbyist Registration
UNIT COST
$25.00
TOTAL AMOUNT DUE
Check# 1 0943
BALANCE DUE
AMOUNT
$25.00
$25.00
($25.00)
$0.00
Note:
Disclaimer: All transactions are subject to review/verification. The Clerk reseNes the right to correct for clerical errors and to
assess or refund charges as needed.
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