Form PAS Page 1 of 2 (Rev. 02/09) Please type, print in ink or file on-line Office use only File # Elaine F. Marshall, Secretary of State Principal Amendment Statement 2009 Previous Registration Information Legal 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:_________________________ E-Mail Address of Principal’s Authorized Officer (see ** below):____________________________________ Amended Principal Information Complete Name of Principal*__________________________________________________________________ Business Address of Principal (Physical NOT a P.O. Box): _________________________________________ 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:____________________ E-Mail Address of Principal’s Authorized Officer (see ** below): ____________________________________ *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 Lobbyist Registration Statement (Form LR-RS). ** If you do not provide an email address on this form and do not mark the box to receive notices in another format (see box below), we are under no obligation to inform you of report due dates, form changes, or any other information we provide via these avenues. Please check if applicable. Principal is requesting nonprofit status under 26 U.S.C. § 501(c)(3) and has attached a copy of Application for Waiver/Reduction of Registration Fees for § 501(c)(3) nonprofits. 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 PAS Page 2 of 2 (Rev. 02/09) CERTIFICATION I hereby certify that all information disclosed in this “Principal Registration and Lobbyist Authorization Statement 2009” is true, complete and correct in accordance with N.C.G.S. §120C-206, and authorize the above named lobbyist to lobby on behalf of the Principal for the calendar year 2009. By signing this certification, I understand the principal through its authorized officer or representative has an affirmative duty to understand the rules and to comply with the Lobbying Law, including filing reports as the law requires. _____________________________________________________ _________________ Signature of Principal’s Authorized Officer Date (Complete only if Preparer is NOT Authorized Officer) Report Preparer’s Identity/Signature (18 NCAC 12 .0209) Printed Complete Name of Report Preparer: ______________________________________________________ Signature of Report Preparer: _________________________________________________________________ • • • This form must be filed by all principals who have employed or retained a lobbyist within ten days after a Lobbyist Registration Statement has been filed with the Secretary of State. Information on this form should correspond to information provided in the Lobbyist Registration Statement (Form LRRS). Registrations are effective from the date of filing until January 1 of the following year unless written notification is received prior to that date. The principal shall file a new registration statement after that date. The fee of one hundred dollars ($100.00) is due and payable to the Secretary of State when the principal’s FIRST Registration/Authorization statement is filed each calendar year for a lobbyist under G.S.§120C-207(a). 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) 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, N.C. 27601-2903; (3) Electronically by electronic mail 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, 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. 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