Form LAS Page 1 of 3 (Rev. 12/10) Elaine F. Marshall, Secretary of State Lobbyist Amendment Statement 2011 Previous Registration Information Full Name of Lobbyist:______________________________________________________________ Lobbyist’s Firm Name (If Applicable):___________________________________________________ Business Address (Physical): ________________________________________________________ Mailing Address:___________________________________________________________________ Telephone No.:____________________________ Fax No.:________________________________ E-Mail Address:___________________________________________________________________ Optional secondary e-mail address (Example: Administrative Assistant): ______________________ Answer as you did on original registration. Answer “yes” or “no” on lines 1 & 2. If the answer to either 1 or 2 is yes, the answer to 3 must be “yes” or “no.” If the answer to 1 & 2 is no, answer 3 may be n/a. (1) _______ I am a former public servant. (2) _______ I am a former employee of a state agency ________________________________ and may lobby the state agency that previously employed me. (MUST enter state agency name) (3) _______ It has been 6 months or more since I held the position of public servant or state employee. Amended Lobbyist Information Full Name of Lobbyist:______________________________________________________________________ List all Principals affected by this amendment: __________________________________________________ Firm Name of Lobbyist (If Applicable):__________________________________________________________ 1 Check all applicable boxes: Lobbyist is not a member of a Firm  Lobbyist is an employee of the Principal  Business Address (Physical NOT a P.O. Box):___________________________________________________ Mailing Address:__________________________________________________________________________ Telephone No.:_____________________________ Fax No.:_______________________________________ E-Mail Address (see page 3): _______________________________________________________________ Optional secondary e-mail address (Example: Administrative Assistant): ______________________________ Only complete this if you are changing previous registration’s answers. Answer “yes” or “no” on lines 1 & 2. If the answer to either 1 or 2 is yes, the answer to 3 must be “yes” or “no.” If the answer to 1 & 2 is no, answer 3 may be n/a. (1) _______ I am a former public servant. (2) _______ I am a former employee of a state agency ________________________________ and may lobby the state agency that previously employed me. (MUST enter state agency name) (3) _______ It has been 6 months or more since I held the position of public servant or state employee. 1 You must check a box OR complete the Firm Name Section above otherwise this registration will be rejected. American LegalNet, Inc. www.FormsWorkFlow.com Form LAS Page 2 of 3 (Rev. 12/10)  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). General Subjects on Which the Lobbyist Intends to Lobby Enter codes from the subject identification table located below. List all applicable categories. A statement of ALL will not be accepted. Code 1 Subject Agriculture, horticulture, farming, and livestock Code 17 2 3 4 5 6 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 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 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 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 (*must specify):________________________ ___________________________________________ 16 Government, state 7 8 9 10 11 12 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 ________________ Certification I hereby certify that all information disclosed in this “Lobbyist Amendment Statement 2011” is true, complete and correct in accordance with G.S. §120C-200. 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 Lobbyist _______________________________ Date American LegalNet, Inc. www.FormsWorkFlow.com Form LAS Page 3 of 3 (Rev. 12/10) Instructions 1. Do Not Use This Form If You Are Registered For Economic Information Protection. 2. Registration triggers reporting obligations. Quarterly reports must be filed regardless of whether you have any reportable expenditures. 3. Registration will expire on January 1 of the following year unless written notification of termination or resignation is received prior to that date. The lobbyist shall file a new registration statement for each year. The fee of one hundred dollars ($100.00) is due and payable to the Secretary of State at the time of each lobbyist registration. G.S. §120C-201(a). Note: Registration must take place within one day of lobbying. 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 1 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