2012/2013Collier County Clerk of Courts Expires LA/�
3299 Tamiami Trail E. (Clerk's office only)
Suite 401, Bldg. F, 4`h Floor
Naples, Florida 34112
BOARD OF COUNTY COMMISSIONERS
LOBBYIST REGISTRATION FORM
Name Date
Business Name , C e
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Business Address '?6 `� ��i¢�la — ✓t��
City k��4c� State Zip Code
Business Telephone Contact Person
Lobbyist E -mail f 6qe r Q. AT7-L. lo,,�ec/"i c,e . Lc lk"s
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 CLIENVENTITY REPRESENTED:
Name C�'7�j ,� �re�,rrr�s�LGCL. Name (f
Address 5Aote ,w I_eLkj,4S7 Address
City
Zip Code City
3. Name 4. Name
Address M.
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Address
City Zip Code City
(ATTACH ADDITIONAL CLIENT SHEETS, IF NECESSARY)
State of Florida
County of Collier
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Zip Code
Zip Code
LoliWst Signature
This registration was sworn (or affirmed) and subscribed before meat r_ day of,
iC_, 201 a-, by
Personally Known BY:
Produced ID deputy ` 1 ublic
Type of ID Produced DtZ-
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`a ' ` Revised: 08/2011
Receipt# 007280682
9/25/2012 11:01:54 AM
<3t; Dwight E. Brock
Clerk of the Circuit Court
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Customer Deputy Clerk Clerk Office Location
ROGER RICE BMR CASHIER Collier County Govt. Center
ATTORNEY ROGER RICE MinutesandRecords @CollierClerk.co Building F, 4th Floor
9010 STRADA STELL CT STE m 3299 Tamiami Trail East, Suite
207 239- 252 -2646 401
NAPLES, FL 34109 -4427 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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