2021/2022 Collier County Clerk of Courts Expires C9 atav
3299 Tamiami Trail E. (Clerk's of ce only)
Suite 401, Bldg. F, 41h Floor
Naples, Florida 34112
BOARD OF COUNTY COMMISSIONERS
LOBBYIST REGISTRATION FORM
3AineSName 1,�Y A-N 1 1C S Date 2 b ZoZ
Business Name J Q 'j( '+r+s po,L T M W VN N 6 -
Business Address 41 ) ) 7 t A V G S'IA)
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City (� � State �L Zip Code
Business Telephone 23 r-44J g'z761 Contact Person jAme-
Lobbyist E-mail ,J t 1' 5-vV t-e ( frts N . C3 M
Notice for Lobbyis : The annual registration fee is $25.00 per Lobbyist, per Collier County
Ordinance No. 2003-53, and amended by Ordinance 2004-05, Ordinance 2007-24 and Ordinance
2013-39. Please make payment(s) to: Collier Clerk of Court.
(Mail to the address listed at the top of the form)
NAME AND ADDRESS OF EACH CLIENT/ENTITY REPRESENTED:
1. Name 2. Name
Address Address
City/State Zip City/State Zip
3. Name 4. Name
Address Address
City/State Zip City/State Zip
(ATTACH ADDITIONAL CLIENT SHEETS,IF NECESSARY)
State of Florida
County of Collier
Lo s byis/lignatur �� .
This registration was sworn (or affirmed) and subscribed fore me thi ..:.'day of,
20 c3) , by Ja,AC'.s
Personally Known BY.
Produced ID Deputy lerk/Nota Publi
Type of ID Produced
Rev. ed:08/2019
Receipt# 008469877
10/26/2021 9:13:23 AM
RCOil4v Crystal K. Kinzel Clerk of the Circuit Court and Comptroller
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Customer Deputy Clerk Clerk Office Location
JMB TRANSPORTATION BMR CASHIER Collier County Govt. Center
ENGINEERING, INC. 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
Check# 1019 ($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.
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