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2016/2017
Collier County Clerk of Courts Expires 3299 Tamiami Trail E. (Clerk's Office Only) Suite 401, Bldg. F,4th Floor Naples, Florida 34112 COLLIER COUNTY LOBBYIST REGISTRATION FORM Lobbyist Name J A-f►^ s 3A N -S Date 6 - 21 -Z017 Business Name J M G 1(L 4 tis o g 1.ki P 1✓ e-r-6 Business Address 411 1 7 ' Avt S 1 City A APL E ' State 1" L Zip Code ' ' 15 Business Telephone 2-?61 '3 9 8.^3 707 Contact Person ) 'i" ~" Lobbyist/Contact E-mail JM b.S t v . MSN` GO An Notice for Lobbyists: The annual registration fee is$25.00 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 ,N � A L � � �� 1 s 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 t S._ ature This registrar' n wa worn(or affirmed) and subscribed before me this day of 201— , by L1 DA i Personally Known BY: 0 Produced ID Deputy Cler ' �ttry P�blic Type of ID Produced w ''�• w•. CGS, Revised.08/2014 ti �6,f Receipt# 007809174 6/27/2017 2:04:40 PM Dwight E. Brock Clerk of the Circuit Court crti ��4~ ©fff@aI �Zc�@�e� _ M t Customer Deputy Clerk Clerk Office Location JMB TRANSPORTATION BMR CASHIER Collier County Govt. Center ENGINEERING MinutesandRecords@CollierClerk.co Building F, 4th Floor 4711 7TH AVE SW m 3299 Tamiami Trail East, Suite NAPLES, FL 34119-4039 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 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. ©Do 00I@[ QG[ ❑@Qo IM Page 1 of 1