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2012/2013 Collier County Clerk of Courts Expires ` 3299 Tamiami Trail E. (Clerk's offic only) Suite 401,Bldg. F, 4th Floor Naples,Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name � v 6 Date 12 (.Z L( Business Name S- `E'') R-tC _ (-A Business Address 1-"G ��r ���� Gz`� Vn e--Q) City 0.1)u S State Zip Code (19 Business Telephone 1 Z I Contact Person `( C Lobbyist E-mail �'�- �� . C c,( . C /,/\ 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 �Qr' f '-Pa � cc� . � Address J Address ' ) I(1-1 City tom'6 t)/ — Zip Code-11 City k ft )11 L Zip Code3L1lI`ce' 3. Name 4.Name Address Address City Zip Code City Zip Code (ATTACH ADDITIONAL CLIENT SHEETS,IF NECESSARY) State of Florida ` County of Collier ---� Lo.byist Signature This registration was sworn(or affirmed) and subscribed before me this 2- " day of, -1)ee , 2012 ,by • Personally Known BY: ,�J,: : Produced ID Deputy Clerk/Notary Public•Type of ID Produced k.)t • Revised:08/2011 Receipt# 007299589 12/12/2012 11:17:04 AM 14.V Dwight E. Brock ;t'lJ Clerk of the Circuit Court Customer Deputy Clerk Clerk Office Location STEVEN BRACCI BMR CASHIER Collier County Govt. Center 2590 NORTHBROOKE PLAZA MinutesandRecords @CollierClerk.co Building F, 4th Floor DR STE 208 m 3299 Tamiami Trail East, Suite NAPLES, FL 34119-8101 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. ©01:11:1�Q �® ©OM Page 1 of 1