Louisiana Regulations § 52-I-2131 Executive Lobbying Registration/Renewal

Regulation Text

EXECUTIVE LOBBYING REGISTRATION/ RENEWAL FOR

THE YEAR OF ______________

(Fill in year.)

________________________________

Executive Lobbyist Registration No.

FOR OFFICE USE ONLY

Postmark 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?___________________________________________________________

EXECUTIVE LOBBYING REGISTRATION FORM

______________________________

Executive Lobbyist Registration No .

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

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

ATTACH

2" x 2"

PHOTOGRAPH

HERE

EXECUTIVE LOBBYING REGISTRATION/RENEWAL ATTACHMENT FORM

________________________________

Executive Lobbyist Registration No.

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? ______________________________________________________