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2016/2017 Collier County Clerk of Courts Expires 0 q /I-7-- 3299 Tamiami Trail E. (Clerk's Office Only) Suite 401,Bldg. F, 4th Floor Naples, Florida 34112 COLLIER COUNTY LOBBYIST REGISTRATION FORM CLobbyist Name LA (2) Date___1D 1( Business Name CI cfu_ IQ, 01 reef\ 4k Business Address 3- 1 6 t Aye_ 4..)(4) City State FL- Zip Code 3Y/tO Business Telephone 239-3(, - .r"-oz) Contact Person Ci irt,A Lobbyist/Contact E-mail a a re 0-7. .,e_rt. a ceyt.-- 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: a/)—e dj Pre v 1.Name it.)070 tkii /die c 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 Collier1411//2."... obbyist Signat e, 100 This registration was sworn (or affirmed)and subscribed before me this .z. day„raf" • '• 20 I b , by LV:„..-Personally Known B • eAr. Produced ID Deputy Clerki4tary-pull 2 : - Type of ID Produced "e"-\- • Revised O8/2014 Receipt# 007720889 10/11/2016 9:21:53 AM �,<,,„ Dwight E. Brock jj Clerk of the Circuit Court xn y Customer Deputy Clerk Clerk Office Location GINA GREEN BMR CASHIER Collier County Govt. Center GINA GREEN, PA MinutesandRecords@CollierClerk.co Building F, 4th Floor 3310 1ST AVE NW m 3299 Tamiami Trail East, Suite NAPLES, FL 34120-2704 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 Check# 1602 ($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. ©®11011gOgggala Page 1 of 1