LAC 52:I.2131
| ________________________________Executive Lobbyist Registration No.________________________________Executive Lobbyist Registration No.EXECUTIVE LOBBYING REGISTRATION/ RENEWAL FOR THE YEAR OF ______________ (Fill in year.) |
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, or fax to (225) 763-8787. For information or assistance, call (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. FAX NUMBER
4. BUSINESS ADDRESS
Street and No. City State Zip
MAILING ADDRESS
Street and No. City State Zip
5. EMPLOYER
6. EMPLOYER'S ADDRESS
Street and No. City State Zip
7. LIST BELOW (a) Names of persons, groups, or organizations which you represent and on whose behalf expenditures are made; (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, who pays you?
Page ______ of ________
______________________________Executive Lobbyist Registration No.______________________________Executive Lobbyist Registration No.EXECUTIVE LOBBYING
REGISTRATION FORM
2. Name
Address
Business or purpose
Does this person pay you?
If No, who pays you?
3. Name
Address
Business or purpose
Does this person pay you?
If No, who pays you?
4. Name
Address
Business or purpose
Does this person pay you?
If No, who pays you?
CERTIFICATION OF ACCURACY
ATTACH2" x 2"PHOTOGRAPHHEREATTACH2" x 2"PHOTOGRAPHHEREI 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 LSA-R.S. 49:71
et seq. has been deliberately omitted.
_________________________________
Signature of Lobbyist
Page ______ of ________
________________________________Executive Lobbyist Registration No.________________________________Executive Lobbyist Registration No. EXECUTIVE LOBBYING
REGISTRATION/RENEWAL
ATTACHMENT FORM
| Instructions: Please make as many copies of this form as necessary in order to complete Question 7 of the Executive Lobbying Registration/Renewal Form. Fill in your Executive Lobbyist Registration No. in the space provided in the upper right hand corner of the page. Please identify each page with a page number and indicate the total number of pages being submitted. |
1. Name
Address
Business or purpose
Does this person pay you?
If No, who pays you?
2. Name
Address
Business or purpose
Does this person pay you?
If No, who pays you?
3. Name
Address
Business or purpose
Does this person pay you?
If No, who pays you?
4. Name
Address
Business or purpose
Does this person pay you?
If No, who pays you?
Page ______ of ________
AUTHORITY NOTE: Promulgated in accordance with R.S. 42:1134(A).
HISTORICAL NOTE: Promulgated by the Department of Civil Service, Board of Ethics, LR 30:2689 (December 2004), repromulgated LR 31:1236 (June 2005).