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2012/2013 Collier County Clerk of Courts Expires 61/2(7/3 3299 Tamiami Trail E. Suite 401, Bldg. F,4th Floor (Clerk's office only) Naples, Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name ..--;.-; il n 4 S n 4z- r' Date 1 O - 1 0 - I a._._ Business Name ) E Ta I i s 'Pa r K -Pr. Dp e r 4-e..s , L l— C_, Business Address l o 9 9 0 L i v n35 +0 n n R04 of City N a p I e-5 State r (- Zip Code 3 4 1 1 0 Business Telephone c3 9• l-47 9 i Contact Person V o)1 et A 5 e-r Lobbyist E-mail l 42-5 i e r K; 4'5 it 14 r a r t h e r-s . ci a ►'+'L Notice for Lobbyists: The annual registration fee is S25.00 ner Lobb ist, 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 l<E Tal1s %rK. Irepc.rlt'jes,IA-C_ 2. Name Address )L.9 9 0 I i v%ny>-o N Rd Address City Ka?a r (.es Zip Code3 4// O City Zip Code 3. Name 4. Name Address Address City Zip Code City Zip Code (ATTACH ADDITIONAL CLIENT SHEETS,IF NECESSARY) State of Florida ,, 2 County of Collier P Lobb Signature •k This registration was sworn (or affirmed) and subscribed before m- ) ,s__1( Fr a a of •0"j- , 20/7.. , by .lotin 4,1„,,- . CAME CONLEY x Nifty Polk•WO Rorie, 'ersonally Known BY: Mr COMM kp i.2•1$ Produced ID I 'hi! erhiliC . Aug Type of ID Produced 411d."-- Revised:08/2011 Receipt# 007287077 10/19/2012 2:28:34 PM H( , Dwight E. Brock / TJ Clerk of the Circuit Court /./c —I t CM Customer Deputy Clerk Clerk Office Location JOHN ASHER BMR CASHIER Collier County Govt. Center KE TALIS PARK MinutesandRecords @CollierClerk.co Building F, 4th Floor PROPERTIES, LLC m 3299 Tamiami Trail East, Suite 16990 LIVINGSTON RD 239-252-2646 401 NAPLES, FL 34110-3220 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#74501080 ($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. ©O1:1OLJ®T@OQaptun Page 1 of 1