Form LRS Page 1 of 3 (Rev. 12/08) Please type, print in ink or file on-line Office use only File # Elaine F. Marshall, Secretary of State Lobbyist Registration Statement 2009 Lobbyist Information Complete Name of Lobbyist:__________________________________________________________________ Firm Name of Lobbyist (If Applicable):__________________________________________________________ Business Address of Lobbyist (Physical NOT a P.O. Box):__________________________________________ Mailing Address of Lobbyist:__________________________________________________________________ Telephone No. of Lobbyist:_________________________________ Fax No.:__________________________ E-Mail Address of Lobbyist (see **below): ______________________________________________________ Principal Information I wish to add additional authorized officers and have attached Form AAOS-09. Complete Name of Principal*:_________________________________________________________________ Business Address of Principal (Physical):________________________________________________________ Name of Principal’s Authorized Officer:_________________________________________________________ Title of Principal’s Authorized Officer: _________________________________________________________ Mailing Address of Principal’s Authorized Officer:_________________________________________________ Telephone No. of Principal’s Authorized Officer:______________________ Fax No.:_____________________ E-Mail Address of Principal’s Authorized Officer (see ** below): ___________________________________ Principal has requested nonprofit status under 26 U.S.C. §501(c)(3): Yes Please check if attached:   No  Copy of Application for Waiver/Reduction of Registration Fees for 501(c)(3) * The principal is the entity or person, as defined in N.C.G.S. § 120C-100(a)(11), on whose behalf the lobbyist influences or attempts to influence legislative and/or executive action. The authorized officer is the person designated by the principal to act as the contact person for all lobbying activities. Information included on this form should correspond to information provided on the Principal Registration and Lobbyist Authorization Statement (Form PR-RS/LA). ** 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 these avenues. American LegalNet, Inc. www.FormsWorkflow.com Form LRS Page 2 of 3 (Rev. 12/08) General Subjects on Which the Lobbyist 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 Report Preparer’s Identity/Signature (Rule 18 NCAC 12.0209) Printed Complete 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). Certification I hereby certify that all information disclosed in this “Lobbyist Registration Statement 2009” is true, complete and correct in accordance with N.C.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 LRS Page 3 of 3 (Rev. 12/08) • 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, N.C.G.S. § 120C-201(a). Note: Registration must take place within one day of lobbying. • 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, N.C. 27626-0622; (2) 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, Department of the Secretary of State, 2 South Salisbury Street, Raleigh, N.C. 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®; For further explanation of regulations and guidelines, see Lobbying Guidelines -- General Information (Form LR-GI) NOTE: REGISTRATION TRIGGERS REPORTING OBLIGATIONS. QUARTERLY REPORTS MUST BE FILED REGARDLESS OF WHETHER THERE ARE ANY REPORTABLE EXPENDITURES. DO NOT USE THIS FORM IF YOU ARE REGISTERING FOR ECONOMIC INFORMATION PROTECTION. American LegalNet, Inc. www.FormsWorkflow.com