Form LL-AR (Rev. 12/10) 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 2011 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): 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): Statement of Resignation I hereby resign as liaison for the state agency ____________________________________________ _________________________________________________ Signature of Liaison __________________________ Date American LegalNet, Inc. www.FormsWorkFlow.com Form LLR-SAR Page 2 of 2 (Rev. 12/10) Certification I hereby certify that all information disclosed in this “Liaison Amendment/Resignation Statement” is t complete and correct in accordance with G.S. §120C-200(c). ___________________________________________ ____________________________________ Signature of Liaison Date Preparer Information ________________________________________________________________________________ Signature of Preparer (If Other Than Liaison) Printed Name of Preparer GENERAL SUBJECTS ON WHICH THE LIAISON INTENDS TO LOBBY Enter codes from the subject identification table below. List all applicable categories. A statement of ALL will not be accepted. Code 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Subject Agriculture, horticulture, farming, and livestock Amusements, games, athletics and sports Banking, finance, credit and investments Children, minors, youth, seniors Church and religion Communications, newspaper, television, radio, computers and information technology Consumer affairs Ecology, environment, pollution, conservation, zoning, land and water use Education Elections, campaigns, voting, political parties Equal rights, civil rights, minority affairs Government, taxation, financing, revenue, budget, appropriations, bids, fees, funds Government, county Government, federal Government, municipal Code 17 18 19 20 21 22 Subject Health service, medicine, drugs and controlled substances, health insurance, hospitals Higher education Housing, construction, building codes Insurance (excluding health insurance) Labor, salaries and wages, collective bargaining Law enforcement, courts, judges, crimes, prisons 23 24 Licenses, permits Liquor, alcoholic beverages 25 26 Manufacturing, distribution, services Natural resources, forest and forest products, fisheries, mining and mining products Public lands, parks, recreation Social insurance, unemployment insurance, public assistance, workers compensation Transportation, highways, streets and roads Utilities, power, cable television, gas Other*: (please specify)________________________________ ______________________________________ 27 28 29 30 31 16 Government, state *Registration will be rejected if catagory 31 “Other” is selected and no subject is specified. American LegalNet, Inc. www.FormsWorkFlow.com