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Louisiana Regulations § 52-I-2133 Executive Lobbying Supplemental Registration

⤴ Up to Chapter 21: Executive Branch Lobbyist Disclosure Act

Regulation Text

EXECUTIVE LOBBYING
SUPPLEMENTAL REGISTRATION FORM
________________________________
Executive Lobbyist Registration No.
FOR OFFICE USE ONLY
Postmark 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) 763-8787. For information or assistance, call (225) 763- 8777 or (800) 842-6630. 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 __________________________________________________________
EXECUTIVE LOBBYING
SUPPLEMENTAL REGISTRATION FORM
________________________________
Executive Lobbyist Registration No.
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

History

Promulgated by the Department of Civil Service, Board of Ethics, LR 30:2692 (December 2004), repromulgated LR 31:1239 (June 2005).

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