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2012/2013 Clerk to the Board, Minutes&Records Dept. Expires l7 q C 3299 Tamiami Trail East, Suite#401 (Staff use only) Building F,4th Floor Naples, FL 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name /!y/✓� 61 " l ' /6 (/ Date --7/- .?`(2/3 Business Address /zf./ 4 ///°U<71 46/ /t/// c� S ‘.347i/ 477 Business Telephone 433 7,3 E-Mail c2,917*/J/Q5'd /4.771 "'"I NAME AND ADDRESS OF EACH PERSON OR ENTITY REPRESENTED: 1). Top Hat Holdings, LLC 1471 Airport Pulling Road North Naples, FL 34104 2). (PLEASE ATTACH ADDITIONAL SHEETS,IF NECESSARY) ffi � Lobby.ignature State of Florida County of Collier The foregoin registr9tion was sworn to and su scr'b d b9fore me on this (� day of C , by gt�i7��/,%/,i� �f,who is persona knnwia to me or has roduced ,®%%%%%,, as identification and who did take an oath. oeQP-cRIClA FA'°'o,��� °�� July 19 ma ?•, sV*90 Deputy Clerk/Notary Public The annual registration feeis1, 'byist,according to Collier County Ordinance No.2003-53,as amen iiYdinance 2004-05 and Ordinance 2007-24. Please make payment and mail to: Collier County Clerk of Courts or Dwight E. Brock,Clerk of Courts(at the address listed at the top of the form). Receipt# 007322145 3/12/2013 12:25:39 PM ,,,y- ki,--'? Dwight E. Brock Clerk of the Circuit Court w` D o 0 .\``-:-_.11-if:LjO/ ( 0 `71- 7,_, - Li L a , ff1Cc4° 1 0 )1R Customer Deputy Clerk Clerk Office Location WAYNE MITCHELL BMR CASHIER Collier County Govt. Center 1471 N. AIRPORT ROAD MinutesandRecords @CollierClerk.co Building F, 4th Floor NAPLES, FL 34104 m 3299 Tamiami Trail East, Suite 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 Deposit Account#: D-03450 ($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. ©Qo 00hCOQa ©Qo [N'�l Page 1 of 1