LAC 52:I.1907. Lobbying Registration Form

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, (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