LAC 52:I.1909. Lobbying Supplemental Registration Form

Instructions 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