La. Admin. Code tit. 52 § I-1909
LOBBYING SUPPLEMENTAL REGISTRATION FORM To be used for changes to registrations and terminations. |
_____________________ Lobbyist's Registration Number |
FOR OFFICE USE ONLY Postmark Date:______ |
· Print in ink or type.
· Complete form and return to the Board of Ethics, 2415 Quail Dr., 3rd Floor,
Baton Rouge, LA 70808, (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
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. Have you ceased or terminated all lobbying activities requiring registration? Yes _____ No _____
7. 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 ___________
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 the Lobbyist Disclosure Act [LSA-R.S. 24:50 et seq.] has been deliberately omitted.
_____________________________
Signature of Lobbyist
La. Admin. Code tit. 52, § I-1909