2011/2012 ( � %Collier County Clerk of Courts Expires {/
3299 Tamiami Trail E. (Clerklofficeonly)
Suite 401,Bldg. F,4th Floor (Clerk/
office
Florida 34112
BOARD OF COUNTY COMMISSIONERS
LOBBYIST REGISTRATION FORM
Name I?A( RC) Date I 3111
Business Name 12 n Vf- ;k-Fp) t2
Business Address l • I (-24V2-- Pic t 71 I O
�G 90/
City � �(�--- State �''2- Zip Code
Business Telephone 311( °CV Contact Person Z 11-1,00 (CA/Th
r +
Lobbyist E-mail t i i� r' -. -�-U 1 'S AT-1-13,1a- S.1
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 CUY'\Sc(L)?„-; •.-1() S W / Pka. Name
Address 1 (-1 Sc' M L- Address
City /'QL. _ ) Zip Code )"1) " - 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 st Signa e
Cr vitivt
This registration was sworn(or affirmed) and subscribed .-
J . , 20 tt ,by
Personally Known
Produced ID Dept le>k o v <P . is
Type of ID Produced `�� ry'4 j
Revised:08/2011
Receipt# 007199648
11/3/2011 9:36:33 AM
j,,,s <<,, Dwight E. Brock
1 Clerk of the Circuit Court
■ri
i o o o
'`` giff
Customer Deputy Clerk Clerk Office Location
RALF GUNARS BROOKES BMR CASHIER Collier County Govt. Center
RALF BROOKES ATTORNEY MinutesandRecords @CollierClerk.co Building F, 4th Floor
1721 SE 39TH ST m 3299 Tamiami Trail East, Suite
CAPE CORAL, FL 33904-5080 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.
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