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2017/2018 Collier County Clerk of Courts Expires 0 3299 Tamiami Trail E. (Clerk's 0 ce Only) Suite 401, Bldg. F, 4th Floor Naples,Florida 34112 COLLIER COUNTY LOBBYIST REGISTRATION FORM eTh Lobbyist Name ft 4 14 /4-91A-P ?-y IL_ Date LI /9 423 — Business Name A'Of ill -I/ Le. — 7-Y \ ei IA...) P1)61'1 t - C Business Address /; (=> a Lf Tin/hilt c_,' i tk g 5 City 06 11 \ca.> State Ft" Zip Code 344 L , t I / Business Telephone C., 1-- ‘ VI Ct. Contact Person 3--' '-/14 t/e 61A v v‘x Lobbyist/Contact E-mailci_tm Aroticejor Lobkvists: The annual registration fee is$25.00per Lobbyist,per Collier Count),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 Dwieht E. Brock, Clerk of Courts(ADDRESS ABOVE) NAME AND ADDRESS OF EACH CLIENT/ENTITY REPRESENTED: 1 1.Name e kCe:". (.--61/. PQ/4--. 2.Name Address Address City N cft. 27) \1 2, Zip Code,' City Zip Code 3.Name 4.Name Address Address City Zip Code City Zip Code (ATFACH ADDITIONAL CLIENT SHEETS,IF NECESSARY) State of Florida _- - T __— County of Collier ./.. Lobbyist Signa ' e 1 This registration was sworn (or affirmed and subscribed before e this /Ct-/(1 day of -1 ( , 20 1 , by VYVINAL, /4 ckalvtUaLl , I , B Personally Known Y) Produced ID ,..- Deputy Clerk/Notary P blic Type of ID Produced Revised:08/2014 Receipt# 007913200 4/19/2018 9:25:25 AM .oti4K ,, c<>U Dwight E. Brock o.-o,, " Clerk of the Circuit Court it r icJ 0 D a a aaC a? a„ Ca _ EDF Customer Deputy Clerk Clerk Office Location ADAMCZYK LAW FIRM, LLC BMR CASHIER Collier County Govt. Center (MARK ADAMCZYK) MinutesandRecords@CollierClerk.co Building F, 4th Floor m 3299 Tamiami Trail East, Suite 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. ©0U0hlYa® o@C Page 1 of 1