La. Admin. Code tit. 52 § I-2133

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Current through Register Vol. 50, No. 11, November 20, 2024

Section I-2133 - Executive Lobbying Supplemental Registration

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

La. Admin. Code tit. 52, § I-2133

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

AUTHORITY NOTE: Promulgated in accordance with R.S. 42:1134(A).