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2021/2022
Collier County Clerk of Courts Expires © / �a� 3299 Tamiami Trail E. (Clerk's office only) Suite 401, Bldg. F, 4'' Floor Naples, Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name ( ,'1L-r-" ,p W- L- Date 7 ( `— a'') - Business Name AU t-(_i \J1' ITj PLi—Q Business Address 0 6,,i L.4__('_ c U/ j-- - -)4 a6 City / V1\T:i -S State FL, Zip Code Business Telephone ,Q. 6 Q Contact Person ike_ Ct tAAC-7//\-7--- Lobbyist E-mail �k pwrk 2 c_l/4ike. (a-ui :(•U -.0 -* 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 '�' \`CGv �/ e ro 2. Name Address %oc=-(Ilp/Y\ ✓ ''e pir:Address City/State ikj \� Zip City/State Zip J 3. Name 4. Name Address Address City/State Zip City/State Zip (ATTACH ADDITIONAL CLIENT SHEETS,IF NECESSARY) •0' State of Florida l --"e— County of Collier . • ,: Lobbyist Signature '� - '-:a This registration affjfined2n 4`(ubscribed before me dayofS.061 20' , by Personally Known BY: (it,t/Lk roduced ID Deputy Cler Public Type of ID Produced Revised:08/2019 Receipt# 008593830 7/12/2022 8:01:13 AM `ov,,,F.Rco,,,,,,, Crystal K. Kinzel Clerk of the Circuit Court and Comptroller 0 gq g_ _,,,_' _ la-_ @Gm--7 _ —JD He CtRO Customer Deputy Clerk Clerk Office Location MARK ADAMCZYK BMR CASHIER Collier County Govt. Center ADAMCZYK LAW FIRM MinutesandRecords@CollierClerk.co Building F, 4th Floor 9130 GALLERIA CT m 3299 Tamiami Trail East, Suite NAPLES, FL 34109-4380 239-252-2646 401 P.O. Box 413044 Naples, Florida 34101-3044 1 Product QUANTITY DESCRIPTION UNIT COST AMOUNT 2 BMR Lobbyist Registration $25.00 $50.00 TOTAL AMOUNT DUE $50.00 Check#4331 ($50.00) 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. VODDbGIT@UQ gOrM Page 1 of 1