Form LL-AR (Rev. 12/09) Please type, print in ink or file on-line Please Check: Amendment Resignation Office use only File # Elaine F. Marshall, Secretary of State Liaison Amendment/Resignation Statement 2010 Previous Registration Information Full Name of Liaison:__________________________________________________________________________________________ Liaison’s State Agency Name: ___________________________________________________________________________________ Business Address of Liaison (Physical):____________________________________________________________________________ Mailing Address of Liaison: _____________________________________________________________________________________ Telephone No.: _________________________ Fax No. _________________________ E-Mail Address: ________________________ Subject Codes for Lobbying Activity (Please use the codes on Page 2 of the Liaison Registration): Amended Registration Information Full Name of Liaison:__________________________________________________________________________________________ Liaison’s State Agency Name: ___________________________________________________________________________________ Business Address of Liaison (Physical):____________________________________________________________________________ Mailing Address of Liaison: _____________________________________________________________________________________ Telephone No.: _________________________ Fax No. ______________________ E-Mail Address: __________________________ Subject Codes for Lobbying Activity (Please use the codes on Page 2 of the Liaison Registration): Statement of Resignation I hereby resign as liaison for the state agency _____________________________________________________. ________________________________________________ Signature of Liaison ____________________________________ Date Certification I hereby certify that all information disclosed in this “Liaison Amendment/Resignation Statement” is true, complete and correct in accordance with N.C.G.S. §120C-200(c). ________________________________________________ ____________________________________ Signature of Liaison Date Preparer Information __________________________________________________________________________________________ Signature of Preparer (If Other Than Liaison) Printed Name of Preparer American LegalNet, Inc. www.FormsWorkFlow.com