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2016/2017 Collier County Clerk of Courts Expires 0 I LU/7 3299 Tamiami Trail E. (Clerk's o ce Only) Suite 401, Bldg. F,4th Floor Naples,Florida 34112 COLLIER COUNTY LOBBYIST REGISTRATION FORM Lobbyist Name Meti 1L e—� Date 2 1-V1 j Business Name ik 1 Ce If — FL-ob 6 ekck 04, 6-4 V ,. L t..IT Business Address EGC , C�ai'L , o- City 0 C4.6c RAQ`J3 State_ --- Zip Code 3(3 1-- Business Telephone - ''°' 6t7/ q-1-301Contact Person ilk kct-j � /L' - Lobbyist/Contact E-mail Mi k— ILl,l�� cS VG {k) ' C Notice for Lobbyists: The annual registration fee is 525.00 per Lobbyist,per Collier County Ordinance No. 2003-53, as amended by Ordinance 2004-05, Ordinance 2007-24 and Ordinance 2013-39. Payments made out to: Collier County Clerk of Courts or Dwight E. Brock. Clerk of Courts(ADDRESS ABOVE) NAME AND ADDRESS OF EACH CLIENT/ENTITY REPRESENTED: 1.Name 2.Name Address Address City Zip Code City Zip Code 3.Name 4.Name Address Address City Zip Code City Zip Code (ATTACH ADDITIONAL CLIENT SHEETS,IF NECESSARY) '`,v State of Florida 1 — ,,'`' 1 County of Collier ,.. ` •z•°°°"'••.;'' °• Lobbyist Sign ile ."; • ." : L, f its c This registration was wo (or affirmed and subscribed before me this l rr n_ 20 t� � ) •��� day df r� by . ��Ku' / C.� . sem, 0 r • c� J u cs `'3 Zf�' Personally Known BY: , ' r _j `< :C-- - ..•' Ni Produced ID i ,, De ty Cle o : . ' 0\ ,`. Type of ID Produced Y r• V`L- Revised:08/2014 Receipt# 007776180 3/27/2017 12:00:49 PM ,`,,>„Rt.>� .t Dwight E. Brock ' Clerk of the Circuit Court ,( "„,,-- ,_, L .__, i- .___- _,, ,-, „, ____., _J Li-J Customer Deputy Clerk Clerk Office Location MICHAEL KELLER BMR CASHIER Collier County Govt. Center ALLIANCE NRG-FLORIDA MinutesandRecords@CollierClerk.co Building F, 4th Floor PACE PROGRAM m 3299 Tamiami Trail East, Suite 555 FEDERAL HW SUITE 239-252-2646 401 #300 P.O. Box 413044 BOCA RATON, FL 33432 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. J ©0[11EgIT©lkgggpth] Page 1 of 1