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2019/2020 Collier County Clerk of Courts Expires �` P' /1, 3299 Tamiami Trail E. (Clerk's off. only) Suite 401, Bldg. F, 4th Floor Naples, Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name tet/k IY)c - Date it9 7-'71 Business NameACLIY/C., lj( LAANj Business Address -/ (3() 6A,-e4 City() 14.-3 State 1 Zip Code 341 6 Business Telephone 63 I^ G 16 Contact Person �1t Lobbyist E-mail vY l f arc -iI1 \N/41 f"i-1 • C�yyt 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, Ordinance 2007-24 and Ordinance 2013-39. Please make payment(s) to: Collier Clerk of Court. (Mail to the address listed at the top of the form) NAME AND ADDRESS OF EACH CLIENT/ENTITY REPRESENTED: 1. Name ` O1lrn' 1 .0610- 2. Name ? Co../ Z- ke Address `` Address / City/State il/1).\, `) Zip City/State thf Zip 3. Name 4. Name Address Address City/State Zip City/State Zip (ATTACH ADDITIONAL CLIENT SHEETS,IF NECESSARY) State of Florida County of Collier r_ Lobbyist Signature This registration was sworn (or a firmed) and subscribed before me this_ 9 dayof, COI x Personally Known BY: k,'�-Q, T Produced ID eputy Clerk/Notary Public Type of ID Produced Revised:08/2019 Receipt# 008130813 10/22/2019 8:54:45 AM co��,Ea�o�Nry Crystal K. Kinzel Clerk of the Circuit Court and Comptroller �� o 0 0 0.0 Mg 1E C1 Customer Deputy Clerk Clerk Office Location MARK ADAMCZYK BMR CASHIER Collier County Govt. Center ADAMCZYK LAW FIRM, LLC MinutesandRecords@CollierClerk.co Building F, 4th Floor 9130 GALLERIA CT STE 201 m 3299 Tamiami Trail East, Suite NAPLES, FL 34109-4381 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 Check# 114 ($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. ©®11 DCgTia®TBZogOrM Page 1 of 1