La. Admin. Code tit. 52 § I-1907
LOBBYING REGISTRATION FORM To be used for initial registrations and renewals |
_____________________ Lobbyist's Registration Number |
FOR OFFICE USE ONLY Postmark Date:______ |
· 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
ATTACH 2" x 2" PHOTOGRAPH HERE |
La. Admin. Code tit. 52, § I-1907