Form LLR-SAS Page 1 of 4 (Rev. 12/09) Elaine F. Marshall, Secretary of State Liaison Registration and State Agency Authorization Statement 2010 NO REGISTRATION FEE REQUIRED Liaison Personnel Information Complete Name of Liaison:___________________________________________________________________ Complete Name of State Agency, Board or Commission: ___________________________________________ Business Address of Liaison (Physical):_________________________________________________________ Mailing Address of Liaison: __________________________________________________________________ Telephone No. of Liaison:______________________________ Fax No.:______________________________ E-mail Address of Liaison:___________________________________________________________________ State Agency Information Complete Name of State Agency*:____________________________________________________________ Address of State Agency (Physical):___________________________________________________________ Complete Name and Title of Contact Person:____________________________________________________ Mailing Address of Contact Person:____________________________________________________________ Telephone No. of Contact Person:________________________________ Fax No.:______________________ E-Mail Address of Contact Person: ____________________________________________________________ * The State Agency means all agencies and constitutional officers of the State, inclusing all boards, departments, divisions, constituent institutions of The University of North Carolina, and other units of government in the executive branch, on whose behalf the liaison influences or attempts to influence legislative and/or executive action. Both Liaison and State Agency Contact Person must sign certification. American LegalNet, Inc. www.FormsWorkFlow.com Form LLR-SAR Page 2 of 4 (Rev. 12/09) 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 Subject Code 1 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 17 27 28 13 14 15 Equal rights, civil rights, minority affairs Government, taxation, financing, revenue, budget, appropriations, bids, fees, funds Government, county Government, federal Government, municipal 16 Government, state 2 3 4 5 6 7 8 9 10 11 12 Subject 18 19 20 21 22 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)____________________________________ ___________________________________________ 29 30 31 *Registration will be rejected if catagory 31 “Other” is selected and no subject is specified. REPORT PREPARER’S IDENTITY/SIGNATURE (RULE 18 NCAC 12 .0209) Printed Full Name of Report Preparer: _______________________________________________________ Signature of Report Preparer: _________________________________________Date:__________________ The Division will send notices regarding filing due dates electronically at no charge. If you desire to receive notices from our office in another format, please indicate that by checking the box and you will be invoiced according to N.C.G.S. §132-1(b). American LegalNet, Inc. www.FormsWorkFlow.com Form LLR-SAR Page 3 of 4 (Rev. 12/09) Liaison and State Agency Contact Person Certifcation LIAISON CERTIFICATION I hereby certify that all information disclosed in this “Liaison Registration and State Agency Authorization Statement 2010” is true, complete and correct in accordance with Article 2 of Chapter 120C. By signing this certification, I understand I have an affirmative duty to understand the rules and to comply with the Lobbying Law, including filing reports as the law requires. _______________________________________________________ ________________________________ SIGNATURE OF LIAISON DATE _________________________________________________________________________________________ STATE AGENCY AUTHORIZATION CERTIFICATION I hereby certify that all information disclosed in this “Liaison Registration and State Agency Authorization Statement 2010” is true, complete and correct in accordance with Article 2 of Chapter 120C. By signing this certification, I understand I have an affirmative duty to understand the rules and to comply with the Lobbying Law, including filing reports as the law requires. __________________________________________________ SIGNATURE OF STATE AGENCY CONTACT PERSON ________________________________ DATE American LegalNet, Inc. www.FormsWorkFlow.com Form LLR-SAR Page 4 of 4 (Rev. 12/09) • Registration and authorization will expire on January 1 of the following year unless written notification is received prior to that date or within one day of when the liaison begins to lobby. The liaison and state agency shall file a new registration statement after that date or within one day after the liaison begins to lobby. No registration fee is required. • FILING SUBMISSION LOCATIONS AND METHODS Each required filing shall be submitted to the Department by one of the following methods: (1) By United States mail at the following address: Lobbying Compliance Division, Department of the Secretary of State, P. O. Box 29622, Raleigh, NC 27626-0622; (2) In person or by a designated delivery service authorized pursuant to G.S. 1A-1, Rule 4 at the following street address: Lobbying Compliance Division, Department of the Secretary of State, 2 South Salisbury Street, Raleigh, NC 27601-2903; (3) Electronically by electronic mail via the Internet site at the following address: lobbyistfiling@sosnc.com. Any document(s) attached to the filing other than the form or report shall be compatible with or convertible to the most recently issued version of Microsoft Word®; or (4) By facsimile for filings not requiring a fee to (919) 807-2205, provided the original signed document is received by the Department within seven days following the Department's receipt of the faxed transmission. A filing for which the original is not received or postmarked within seven days following the Department's receipt of the faxed transmission is void. A document received by hand-delivery or fax after 5:00 p.m. is considered to be received on the following day. NOTE: REGISTRATION TRIGGERS REPORTING OBLIGATIONS. QUARTERLY REPORTS MUST BE FILED REGARDLESS OF WHETHER THERE ARE ANY REPORTABLE EXPENDITURES. For further explanation of regulations and guidelines, see Lobbying Guidelines -- General Information (Form LR-GI) American LegalNet, Inc. www.FormsWorkFlow.com