LAC 52:I.1907
_____________________Lobbyist's Registration Number_____________________Lobbyist's Registration Number
LOBBYING REGISTRATION FORMTo be used for initial registrations and renewalsLOBBYING REGISTRATION FORMTo be used for initial registrations and renewals
FOR OFFICE USE ONLYPostmark Date:______FOR OFFICE USE ONLYPostmark Date:______Instructions
Print in ink or type.
Complete form and return with $110 registration fee to the Board of Ethics,
2415 Quail Dr., 3rd Floor, Baton Rouge, LA 70808, (225) 763-8777 or
(800) 842-6630.
Initial registrations must be submitted within 5 days of (1) employment as a
lobbyist or (2) first action requiring registration. Registrations expire as of
December 31 unless a renewal is submitted between December 1 and January 31.
1. NAME_____________________________________________________
Last First MI
2. BUSINESS PHONE___________________________________________
Area Code and Phone Number
3. BUSINESS ADDRESS____________________________________________________________
Street and No. City State Zip
MAILING ADDRESS_____________________________________________________________
Street and No. City State Zip
4. EMPLOYER____________________________________________________
5. EMPLOYER'S ADDRESS___________________________________________________________
Street and No. City State Zip
6. LIST BELOW (a) Names of persons, groups, or organizations which you represent; (b) the address of each such person, group, or organization you represent; (c) the type of business each is engaged in or the purpose or function of the organization or group; (d) whether or not the client or someone else pays you to lobby.
1. Name
Address
Business or purpose
Does this person pay you? _____
If No, then who pays you?
2. Name
Address
Business or purpose
Does this person pay you? _____
If No, then who pays you?
3. Name
Address
Business or purpose
Does this person pay you? _____
If No, then who pays you?
4. Name
Address
Business or purpose
Does this person pay you? _____
If No, then who pays you?
CERTIFICATION OF ACCURACY
I hereby certify that the information contained herein is true and correct to the best of my knowledge, information, and belief; and that no information required by the Lobbyist Disclosure Act [LSA-R.S. 24:50 et seq.] has been deliberately omitted.
_________________________________________
Signature of Lobbyist
ATTACH2" x 2"PHOTOGRAPHHEREATTACH2" x 2"PHOTOGRAPHHERE
AUTHORITY NOTE: Promulgated in accordance with R.S. 42:1134(A).
HISTORICAL NOTE: Promulgated by the Department of Civil Service, Board of Ethics, LR 30:2680 (December 2004), repromulgated LR 31:627 (March 2005).