Form LRS Page 1 of 3 (rev. 01/11) Elaine F. Marshall, Secretary of State Lobbyist Registration Statement 2011 Lobbyist Information Complete Name of Lobbyist: (Mr./Ms./Dr.) _________________________________________________________ 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 of Lobbyist (Physical NOT a P.O. Box):_________________________________________ ________________________________________________________________________________________ Mailing Address of Lobbyist: _________________________________________________________________ Telephone No. of Lobbyist: _________________________________ Fax No.:_________________________ E-Mail Address of Lobbyist: _________________________________________________________________ Optional secondary e-mail address (Example: Administrative Assistant): ______________________________ Principal Information Complete Name of Principal: ________________________________________________________________ Business Address of Principal (Physical NOT a P.O. Box):_________________________________________ ________________________________________________________________________________________ Name of Principal’s Authorized Officer: (Mr./Ms./Dr.) ________________________________________________ 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: ________________________________________________ Optional secondary e-mail address (Example: Administrative Assistant):_______________________________ □ Check if attaching form RW, Application for Waiver/Reduction of Registration Fees for 26 USC 501(c)(3). NOTE: see page 2 of RW form for fee amount. Registrations submitted without correct fee will be rejected. The question below MUST be answered “yes” or “no”. If yes, include the name of the State Agency . G.S. 120C-200(f). __________ I am a former employee of a state agency ________________________________ (MUST enter state agency name) and I left that employment within the last six months. 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 LRS Page 2 of 3 (rev. 01/11) 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 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 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 SUBJECT Registration will be rejected if Catagory 31 “Other” is selected and no subject is specified.  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). 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 Registration 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 comply with the Lobbying Law and the rules including filing reports as the law requires. Signature of Lobbyist _________________________________________________ Date ___________________ American LegalNet, Inc. www.FormsWorkFlow.com Form LRS Page 3 of 3 (rev. 01/11) INSTRUCTIONS 1. Do Not Use This Form If You Are Registering 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. The principal is the entity or person, as defined in 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 PRRS/LA). 5. 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. 6. 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) 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®; (d) 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 hand-delivery or fax after 5:00 p.m. is considered to be received on the following day. American LegalNet, Inc. www.FormsWorkFlow.com