Louisiana Administrative Code › Title 52 - ETHICS › Part I - Board of Ethics › Chapter 21 - Executive Branch Lobbyist Disclosure Act › Section I-2131 - Executive Lobbying Registration/Renewal

Current through Register Vol. 50, No. 6, June 20, 2024
EXECUTIVE LOBBYING REGISTRATION/ RENEWAL FOR
THE YEAR OF ______________
(Fill in year.)
________________________________
Executive Lobbyist Registration No.
FOR OFFICE USE ONLY
Postmark Date:__________
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?___________________________________________________________
EXECUTIVE LOBBYING REGISTRATION FORM
______________________________
Executive Lobbyist Registration No
.
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
ATTACH
2" x 2"
PHOTOGRAPH
HERE
EXECUTIVE LOBBYING REGISTRATION/RENEWAL ATTACHMENT
				  FORM
________________________________
Executive Lobbyist Registration No.
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?
				  __________________________________________________________
AUTHORITY NOTE:
				  Promulgated in accordance with
				  R.S.
				  42:1134(A).