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2016/2017 Collier County Clerk of Courts Expires °"I 2C17 3299 Tamiami Trail E. (Clerk's ffice only) Suite 401, Bldg. F,4th Floor Naples,Florida 34112 BOARD OF COUNTY COMMISSIONERS LOBBYIST REGISTRATION FORM Name G,„1 D B!�)'1C1.�T TC Date .. -2 i -lilt(Business Name Ort (I-CCCO I I I C Business Address TPC) BO'( -7? C) ) City O G.r ik 5 State FI Zip Code 3 I L1) 1 Business Telephone-231-'1r-CY5-3 5 Contact Person i Lobbyist E-mail 161 A narlk c\cu cr2 'le C 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 and Ordinance 2007-24. Payments made out to: Collier County Clerk of Courts or Dwight E. Brock, Clerk of Courts (ADDRESS LISTED 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) State of Florida County of Collier Lobby s ignature This registration was sworn(or affirmed) and subscribed before me this a I day of, 20 by_Gu9 -D,-VgtKhes1-4-0 . i1. �"" "A GIANNJ►MARIE HARTS q 40 I/ WAk jr Personally Known , My COMMISSION I FF 211433 D I • • Produced ID �`s `���4 EXPIRES:April 5,2019 Deputy Clerk/Notary Public Type of ID Produced Nj"'Fa�°� Bon edThwBu*Notary Services orySen"es Revised:08/2011 Receipt# 007765512 2/27/2017 2:50:47 PM Dwight E. Brock Clerk of the Circuit Court Customer Deputy Clerk Clerk Office Location GUY D. BLANCHETTE BMR CASHIER Collier County Govt. Center SUBSTANCE ABUSE MinutesandRecords@CollierClerk.co Building F, 4th Floor COALITION OF C.C., INC. m 3299 Tamiami Trail East, Suite PO BOX 770759 239-252-2646 401 NAPLES, FL 34107-0759 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# 1997 ($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. CQE ©EIQE@ o©ral Page 1 of 1