CLARK COUNTY LOBBYIST REGISTRATION STATEMENT/ DISCLOSURE FORM Badge # ____________ Return Date _________ Renewal Date _______ Pursuant to Ordinance No. 3754 which states in part that: “Every person who acts as a lobbyist shall, not later than 5 days after the beginning of the activity, file a registration statement with the County Clerk, Commission Division.” • • If registering as an annual lobbyist, this form must be completed once in its entirety. For all subsequent communication, lobbyist need only complete Section 5. Registration statements for annual lobbyists are due no later than January 10th of each calendar year. For lobbyist not registered annually, this form must be completed in its entirety for each communication. Completed forms may also be submitted by fax to the County Clerk, Commission Division at 455-4626. This form can be accessed on the County’s website at: www.co.clark.nv.us/clerk/forms.htm SECTION 1 LOBBYIST’S FULL NAME: _______________________________________________________ APPLICATION DATE: ___________________________________________________________ PERMANENT ADDRESS: ________________________________________________________ BUSINESS NAME: _____________________________________________________________ BUSINESS ADDRESS: __________________________________________________________ SECTION 2 PROVIDE THE FULL NAME AND COMPLETE ADDRESS OF EACH PERSON, GROUP OR ORGANIZATION BY WHOM YOU ARE RETAINED, EMPLOYED, OR ON WHOSE BEHALF YOU ARE APPEARING: NAME/BUSINESS NAME ADDRESS PHONE _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ SECTION 3 PROVIDE A LISTING OF ANY DIRECT BUSINESS ASSOCIATIONS OR PARTNERSHIPS INVOLVING ANY CURRENT COMMISSIONER. THE LISTING MUST INCLUDE ANY SUCH ASSOCIATION OR PARTNERSHIP CONSTITUTING A SOURCE OF INCOME OR INVOLVING A DEBT OR INTEREST IN REAL ESTATE REQUIRED TO BE DISCLOSED IN A STATEMENT OF FINANCIAL DISCLOSURE MADE BY A CANDIDATE FOR PUBLIC OFFICE OR A PUBLIC OFFICER PURSUANT TO NRS 281A. 620: American LegalNet, Inc. www.FormsWorkFlow.com BUSINESS ASSOCIATION/PARTNERSHIP NAME OF CURRENT ELECTED OFFICIAL ________________________________ ______________________________________ ________________________________ ______________________________________ SECTION 4 LIST BELOW THE NAME OF ANY COMMISSIONER FOR WHOM YOU HAVE, FOR COMPENSATION, IN CONNECTION WITH A POLITICAL CAMPAIGN OF THE COMMISSIONER, PROVIDED CONSULTING, ADVERTISING OR OTHER PROFESSIONAL SERVICES SINCE THE BEGINNING OF THE PRECEDING CALENDAR YEAR. NAME ____________________________________ ____________________________________ ____________________________________ DISCLOSURE This section should be completed for each communication with a member of the Board of County Commissioners within 5 days after the communication has occurred. Completed forms may be submitted to the front desk at the County Commissioner’s Office or the Clerk’s Office, Commission Division or faxed to the County Clerk, Commission Division at 455-4626. SECTION 5 LOBBYIST’S FULL NAME: _______________________________________________________ COMMUNICATION DATE: _________________ SUBJECT MATTER DESCRIPTION OR AGENDA ITEM: _______________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ COMMISSIONER CONTACTED: __________________________________________________ _____________________________________________ _________________________ SIGNATURE OF LOBBYIST DATE *An amendment to this registration must be filed with the Clark County Clerk’s Office, Commission Division, if there is a substantial change or addition with respect to the information contained in the original registration statement. American LegalNet, Inc. www.FormsWorkFlow.com