Louisiana Administrative Code › Title 52 - ETHICS › Part I - Board of Ethics › Chapter 19 - Legislative Branch Lobbyist Disclosure Act › Section I-1907 - Lobbying Registration Form

Current through Register Vol. 50, No. 6, June 20, 2024
LOBBYING REGISTRATION FORM
To be used for initial registrations and
							 renewals
_____________________
Lobbyist's Registration Number
FOR OFFICE USE ONLY
Postmark Date:______
· 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
ATTACH
2" x 2"
PHOTOGRAPH
HERE
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  42:1134(A).