LAC 52:I.2133
________________________________Executive Lobbyist Registration No.________________________________Executive Lobbyist Registration No.
EXECUTIVE LOBBYING
SUPPLEMENTAL REGISTRATION FORM
FOR OFFICE USE ONLYPostmark Date:__________FOR OFFICE USE ONLYPostmark Date:__________
| Instructions Print in ink or type. Complete form and return to Board of Ethics, 2415 Quail Dr., 3rd Floor, Baton Rouge LA 70808, or fax to (225) 7638787. For information or assistance, call (225) 7638777 or (800) 8426630. No fee is required. This form must be submitted within 5 days of any changes in your registration form or to add employers or those you represent. It must be submitted within 10 days of any termination of employment or representations. |
1. NAME
Last First MI
NAME CHANGE
Last First MI
2. BUSINESS PHONE
(Area Code) Phone Number
3. FAX PHONE
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. Have you ceased or terminated all lobbying activities requiring registration? Yes______ No_____
8. LIST BELOW (a) Names of persons, groups, or organizations which you are adding or eliminating; (b) the address of each such person, group, or organization listed; (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; and (e) the date of termination if applicable.
1) Name
Address
Business or purpose
New Representation
Does this person pay you?
If No, who pays you? __________________________________________________________
Terminated Representation as of __________________________________________________________
Page 1 of 2
________________________________Executive Lobbyist Registration No.________________________________Executive Lobbyist Registration No.
EXECUTIVE LOBBYING
SUPPLEMENTAL REGISTRATION FORM
2) Name
Address
Business or purpose
New Representation
Does this person pay you? __________
If No, who pays you?
Terminated Representation as of ________________________________
3) Name
Address
Business or purpose
New Representation
Does this person pay you? ____________
If No, who pays you?
Terminated Representation as of
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 LSA-R.S. 49:71 et seq. has been deliberately omitted.
_________________________________
Signature of Lobbyist
Page 2 of 2
AUTHORITY NOTE: Promulgated in accordance with R.S. 42:1134(A).
HISTORICAL NOTE: Promulgated by the Department of Civil Service, Board of Ethics, LR 30:2692 (December 2004), repromulgated LR 31:1239 (June 2005).