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2017/2018 Collier County Clerk of Courts Expires 3299 Tamiami Trail E. (Clerk's OfIicJ Only) Suite 401, Bldg. F,4th Floor Naples, Florida 34112 COLLIER COUNTY LOBBYIST REGISTRATION FORM Lobbyist Name JHAI E_S Date /1/ Z.C2 /1 Business Name \.). Ill T64 Ad Pog T11 Tio Al& Business Address / 7 A V S w City /VA 'L1 State n Zip Code Business Telephone 73t7 —q/4 -Z-nil Contact Person Lobbyist/Contact E-mail 3()1b SW-L. C T) 4/1--C ' ' Notice for Lobkvists: 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 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 • Lobbyist Signature I q-th This registration was sworn(or affirmed) and subscribed before me this day of Naveiv&r, 20 7 , by \CIt.41YleS M. L3 L5 • Personally Known BY: AL e k ,41111111 ___XProduced IDftk---) De.uty Clerk/Notary Ubi i• mum Type of ID Produced Revised:08/2014 Receipt# 007850785 11/14/2017 9:44:04 AM \O¢%COINT,_ Dwight E. Brock ti=; -, Clerk of the Circuit Court 0 iffr C D , - ---,---- III .a ciik,-- j_91) Customer Deputy Clerk Clerk Office Location JAMES M. BANKS BMR CASHIER Collier County Govt. Center JMB TRANSPORTATION MinutesandRecords@CollierClerk.co Building F, 4th Floor ENGINEERING, INC. m 3299 Tamiami Trail East, Suite 4711 7TH AVE SW 239-252-2646 401 NAPLES, FL 34119-4039 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. ©Qo Q11aQT©OQggriM Page 1 of 1