2012/2013Collier County Clerk of Courts Expires y_�D ^ao 1J
3299 Tamiami Trail E. (Cleric's office only)
Suite 401, Bldg. F, 4`h Floor
Naples, Florida 34112
BOARD OF COUNTY COMMISSIONERS
LOBBYIST REGISTRATION FORM
Name �t TbN Date 2
Business Name
Business Address �'� Uyt L Vyt 28z)
City
State te_.
Zip Code��
Business Telephone 4 -r�-,6 Contact Person
Lobbyist E -mail U
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 CLIENUENTITY REPRESENTED:
Address COIDD eCet=Address
City les I Zip Coda�h 10 City
3. Name
Address
4. Name
Address
City Zip Code City
(ATTACH ADDITIONAL CLIENT SHEETS, IF NECESSARY)
State of Florida
County of Collier
his registration was
IT—MI,
Personally Known
�e Produced ID �
Type of ID Produced"Y ,q
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Lobbyist Signature
ibed before.me this
Zip Code
Zip Code
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Revised: 08/2011
Dwight E. Brock
Clerk of the Circuit Court
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Customer
JAMES E. BOUGHTON
JAMES E. BOUGHTON
ARCHITECT
6645 WILLOW PARK DR STE
200
NAPLES, FL 34109 -8989
1 Product
Receipt# 007313746
2/7/2013 8:59:43 AM
Deputy Clerk Clerk Office Location
BMR CASHIER Collier County Govt. Center
MinutesandRecords @CollierClerk.co Building F, 4th Floor
m 3299 Tamiami Trail East, Suite
239 - 252 -2646 401
P.O. Box 413044
Naples, Florida 34101 -3044
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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