Form LLR-SAS Page 1 of 4 (Rev. 12/10) Elaine F. Marshall, Secretary of State Liaison Registration and State Agency Authorization Statement 2011 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: ____________________________________________________ * “State Agency” includes all agencies and constitutional officers of the State, including 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. 12/10) 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 1 13 14 15 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 16 Code 17 Government, state 2 3 4 5 6 7 8 9 10 11 12 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 *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) Print name of Preparer (if other than lobbyist): ___________________________________________________ Signature of 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 G.S. § 132-1(b). American LegalNet, Inc. www.FormsWorkFlow.com Form LLR-SAR Page 3 of 4 (Rev. 12/10) 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 2011” 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 2011” 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. 12/10) Instructions 1. Registration triggers reporting obligations. Quarterly reports must be filed regardless of whether you have any reportable expenditures. 2. Registration will expire on January 1 of the following year unless written notification of termination or resignation is received prior to that date. The liaison and state agency shall file a new registration statement for each year. No registration fee is required. Note: Registration must take place within one day of lobbying. 3. A liaison is any State employee, counsel employed under G.S. §147-17, or officer whose principal duties, in practice or as set forth in that individual's job description, include lobbying legislators or legislative employees. G.S. §120C-100 (a)(8). 4. If you do not provide an email address on this form and do not mark the box to receive notices in another format (page 2 of this document), we are under no obligation to inform you of report due dates, form changes, or any other information we provide via electronic methods. 5. FILING SUBMISSION LOCATIONS AND METHODS Each required filing shall be submitted to the Department by one of the following methods: (a) By United States mail at the following address: Lobbying Compliance Division Dept. of the Secretary of State P. O. Box 29622 Raleigh, N.C. 27626-0622 (b) By hand-delivery or by a designated delivery service authorized pursuant to G.S. §1A-1, Rule 4 at the following street address: Lobbying Compliance Division Dept. of the Secretary of State 2 S. Salisbury Street Raleigh, N.C. 27601-2903 (c) (d) 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®; By facsimile (919-807-2205) for filings not requiring a fee, provided the original signed document is postmarked or delivered to the Department within seven days following the Department's receipt of the faxed transmission. A filing for which the original is not postmarked or delivered to the Department within seven days following the Department's receipt of the faxed transmission is void. A document received by handdelivery or fax after 5:00 p.m. is considered to be received on the following day. American LegalNet, Inc. www.FormsWorkFlow.com