2011/2012 Collier County Clerk of Courts Expires 9 4���
3299 Tamiami Trail E. (Cie -•s office only)
Suite 401, Bldg. F, 4th Floor
Naples, Florida 34112
BOARD OF COUNTY COMMISSIONERS
LOBBYIST REGISTRATION FORM
Name �.q Q ��1 Date D2/1C/2.0 12-
Business Name c.._ ,.) --f..) -- Lc__
Business Address . O ` 7 9
City , I • r...) State Z---- Zip Code ..56-11 q 5
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Business Telephone � -�(��2�� Contact Person � � /�C.�
Lobbyist E-mail 4C-AIY\3 9I1/ f2 (• <vCi....0 Q,26 .2s , Gov(
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:
I. Name k 0, C 6 1 S l4_r14) e41441.h e e o--f 2. Name
Address li Q a lU , Col ilex It Address
CityPcii FT 23 ,,,Lp/Op Code 3f°,is✓ City Zip Code
3. Name 4. Name
Address Address
City Zip Code City Zip Code
(ATTACH ADDITIONAL CLIENT SHEETS,IF NECESSARY')
/7 State of Florida „/ -.'Z'
County of Collier ,
L i bbyist Signature
;t-.
This registration was sworn (or affirmed) and subscribed before me this /0 day of,
f-B R u D Q,, 201)- , by A4I.,W C'. 64%,,v r%
Personally Known BY: n.-e
Produced ID --- Duty le otary Public
Type of ID Produced ;;��''"'`! ;: MONTE LAZA
MY COMMISSION#DD894772
�"%)io: EXPIRES June 01,2013
Revised: 08/2011
(407)398-0153 ='n•idaNOtarySer/ice.c0m
Receipt# 007224705
2/22/2012 9:33:23 AM
. Y"`° � Dwight E. Brock
s. ; \`, Clerk of the Circuit Court
off g C�
Customer Deputy Clerk Clerk Office Location
ALAN BROWN (ISLAND BMR CASHIER Collier County Govt. Center
GARDENERS, INC.) KEVIN MinutesandRecords @CollierClerk.co Building F, 4th Floor
DONLAN (PUBLIX) RICHARD m 3299 Tamiami Trail East, Suite
S. SHANAHAN (RICHARD 239-252-2646 401
SHANAHAN, I P.O. Box 413044
MARCO ISLAND AREA Naples, Florida 34101-3044
CHAMBER OF COMMERCE
1102 N COLLIER BLVD
MARCO ISLAND, FL 34145-
2547
1 Product
QUANTITY DESCRIPTION UNIT COST AMOUNT
3 BMR Lobbyist Registration $25.00 $75.00
TOTAL AMOUNT DUE $75.00
Check#7305 ($75.00)
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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