LAC 52:I.2133. Executive Lobbying Supplemental Registration

EXECUTIVE LOBBYING SUPPLEMENTAL REGISTRATION FORM 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 __________________________________________________________ Page 1 of 2 EXECUTIVE LOBBYING SUPPLEMENTAL REGISTRATION FORM 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 Page 2 of 2