Form PR/LA Page 1 of 2(Rev. 12/10) Elaine F. Marshall, Secretary of State Principal Registration and Lobbyist Authorization Statement 2011 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: ________________________ E-Mail Address of Principal’s Authorized Officer (see ** below): ______________________________________________ Optional secondary e-mail address (Example: Administrative Assistant):_______________________________________ Principal Legal Structure: (Check One) NC Corporation  Limited Liability Company  Unincorporated Association  Foreign Corporation _____________________ (Foreign State of Incorporation)  Non-Profit. If the entity is an unincorporated association, the authorized officer will need to provide a list of all officers. Please attach the list to this registration.  I wish to add additional authorized officers and have attached Form AAOS-11. Lobbyist Information Complete Name of Lobbyist: (Mr./Ms./Dr.)_____________________________________________________________________________ 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: ___________________________________________________________________________ Optional secondary e-mail address (Example: Administrative Assistant): _______________________________________ □ 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 “Principal Registration and Lobbyist Authorization Statement 2011” is true, complete and correct in accordance with G.S. §120C-206, and authorize the above named lobbyist to lobby on behalf of the Principal for the calendar year 2011. By signing this certification, I understand the principal through its authorized officer or representative has an affirmative duty to comply with the Lobbying Law and the rules including filing reports as the law requires. _______________________________________________________________________________________________ Signature of Principal’s Authorized Officer □ Date Check if attaching Form RW, Application for Waiver/Reduction of Registration Fees for 26 U.S.C. 501(c)(3). Note: see page 2 of RW form for fee amount. Registrations submitted without correct fee will be rejected. American LegalNet, Inc. www.FormsWorkFlow.com Form PR/LA Page 2 of 2(Rev. 12/10) 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. 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). 4. This form must be filed by all principals who have employed or retained a lobbyist within 20 business 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 LR-RS). 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 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. 6. FILING SUBMISSION LOCATIONS AND METHODS a. 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