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2022/2023
Collier County Clerk of Courts Expires ©9 "'' 23 3299 Tamiami Trail E. (Clerk's rceonly) Suite 401,Bldg.F,4th Floor Naples,Florida 34112 BOARD OF COUNTY COMMISSIONERS //� LOBBYIST REGISTRATION FORM 1 Name / t 4 {'GW g. doll;14a y Date 2.S A L. I 0) 5 Business Name AfGf 1 N `43 , ,_ S y4 sL[,rt L-n( - Business Address 3So 74 t S4rc04- NdrAd, City /lc?rG S State rL Zip Code 3 y/Q 1 Business Telephone 13 4- $X d- 7 ri y Contact Person S saF Lobbyist E-mail lit( 4j sw. helhdiv0 nt rd• 03 -. Notice for Lobbyists: The annual registration fee is$25.00 per Lobby ist,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 tie# /it oil*.tteft- S 4kM 1A . 2. Name Address 3S 0 7"54. A( Address City/State /6PIG4 f rL Zip3 ye k City/State ' Zip 3. Name 4. Name Address Address City/State—__ Zip City/State . Zip (ATTACH ADDITIONAL CLIENT SHEETS,IF NECESSARY) State of Florida �,,�j�/f County of Collier %�2 .� I" Lobbyist Signature This registratipll was sworn(orsaffirmed)and subscribed before me this o� 3r� AIM of, � . 2022, by (, trlAj YL V Personally Known BY: Produced ID ep Clerk/Notary Public Type of ID Produced -- «�: EU•IZABETH MARTIN • •. MY COMMISSION#GG 231390 � �s` EXPIRES:October 21.2022 Rev Ned:08/2019 •��f cdI•'� Bonded TMu Nobly Public ihlderAers Receipt# 008614928 9/1/2022 7:58:11 AM cepeRCoz Crystal K. Kinzel Clerk of the Circuit Court and Comptroller H3<c ° g E CIRC Customer Deputy Clerk Clerk Office Location MATTHEW HOLLIDAY BMR CASHIER Collier County Govt. Center NCH HEALTHCARE SYSTEM, MinutesandRecords@CollierClerk.co Building F, 4th Floor INC. m 3299 Tamiami Trail East, Suite 305 7TH ST NW 239-252-2646 401 NAPLES, FL 34120 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# 101064433 ($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. ©00011@1T©0@ ggIU Page 1 of 1