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2017/2018 Collier County Clerk of Courts Expires C-7G/ 3299 Tamiami Trail E. (Clerk's iceOnly) Suite 401, Bldg. F,4th Floor Naples, Florida 34112 COLLIER COUNTY LOBBYIST REGISTRATION FORM Lobbyist Name sSe - � G ^ Date — 2 6— I Business Name /4k Are". ...Filo• -d ev-F r S /M4 i3e,g Business Address NS-5— P.;• 4''$ City /?Q<r5 State Zip Code 3 f- 1/O Business Telephone 23f- 517- 44' Contact Person J S$ Lobbyist/Contact E-mail "J 55 l' eD e• C o 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 O 1 2.Name Address )`t cS T`a? K, Address City (l/Ark s Zip Code 3Y I(0 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 Lob y,ist Signature This registration was sw (or affirmed) and subscribed before me this ,.day o C , 20 (7 , by s % i v'urelur Personally Known BY: WA,A , Produced ID Deputy Clerk/Notary P lic Type of ID Produced Revised:08/2014 Receipt# 007821895 8/4/2017 10:21:50 AM r Dwight E. Brock ti Clerk of the Circuit Court J �FT <R<v � agff' - asCc a Customer Deputy Clerk Clerk Office Location JESSE M. PURDON BMR CASHIER Collier County Govt. Center NAPLES AREA BOARD OF MinutesandRecords@CollierClerk.co Building F, 4th Floor REALTORS (NABOR) m 3299 Tamiami Trail East, Suite 1455 PINE RIDGE RD 239-252-2646 401 NAPLES, FL 34109-2139 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# 028689 ($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. ©CQUhQ® ❑ggEla Page 1 of 1