Form PAS Page 1 of 2 (Rev. 12/10) Elaine F. Marshall, Secretary of State Principal Amendment Statement 2011 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):_______________________________ Optional secondary e-mail address (Example Administrative Assistant): _______________________ Amended Principal Information Name of lobbyist(s) affected by this amendment: ________________________________________ Legal 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): ______________________________ Optional secondary e-mail address (Example Administrative Assistant):________________________ CERTIFICATION I hereby certify that all information disclosed in this “Principal Amendment Statement 2011” is true, complete and correct in accordance with G.S. §120C-206. 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  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. 12/10) 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: _________________________________________________________________ Instructions 1. Do Not Use This Form If You Are Registered For Economic Information Protection. 2. Quarterly reports must be filed regardless of whether you have any reportable expenditures. 3. The authorized officer is the person designated by the principal to act as the contact person for all lobbying activities. 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