Louisiana Administrative Code › Title 52 - ETHICS › Part I - Board of Ethics › Chapter 19 - Legislative Branch Lobbyist Disclosure Act › Section I-1909 - Lobbying Supplemental Registration Form

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