LAC 52:I.2131. Executive Lobbying Registration/Renewal

EXECUTIVE LOBBYING REGISTRATION/ RENEWAL FOR THE YEAR OF ______________ (Fill in year.) 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, or fax to (225) 763-8787. For information or assistance, call (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. FAX NUMBER 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. LIST BELOW (a) Names of persons, groups, or organizations which you represent and on whose behalf expenditures are made; (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, who pays you? Page ______ of ________ EXECUTIVE LOBBYING REGISTRATION FORM 2. Name Address Business or purpose Does this person pay you? If No, who pays you? 3. Name Address Business or purpose Does this person pay you? If No, who pays you? 4. Name Address Business or purpose Does this person pay you? If No, 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 LSA-R.S. 49:71 et seq. has been deliberately omitted. _________________________________ Signature of Lobbyist Page ______ of ________ EXECUTIVE LOBBYING REGISTRATION/RENEWAL ATTACHMENT FORM Instructions: Please make as many copies of this form as necessary in order to complete Question 7 of the Executive Lobbying Registration/Renewal Form. Fill in your Executive Lobbyist Registration No. in the space provided in the upper right hand corner of the page. Please identify each page with a page number and indicate the total number of pages being submitted. 1. Name Address Business or purpose Does this person pay you? If No, who pays you? 2. Name Address Business or purpose Does this person pay you? If No, who pays you? 3. Name Address Business or purpose Does this person pay you? If No, who pays you? 4. Name Address Business or purpose Does this person pay you? If No, who pays you? Page ______ of ________