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Principal Amendment Statement 2011 Form. This is a North Carolina form and can be use in Lobbyist Registration Secretary Of State.
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Tags: Principal Amendment Statement 2011, PAS, North Carolina Secretary Of State, Lobbyist Registration
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).
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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.
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