State Agency Amendment Liaison Termination Statement 2011
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State Agency Amendment Liaison Termination Statement 2011 Form. This is a North Carolina form and can be use in Lobbyist Registration Secretary Of State.
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Tags: State Agency Amendment Liaison Termination Statement 2011, SA-LT, North Carolina Secretary Of State, Lobbyist Registration
Form SA-LT (Rev. 12/10)
Please type, print in ink or file on-line
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Amendment
Termination
Office use only
File #
Elaine F. Marshall, Secretary of State
State Agency Amendment/Liaison Termination Statement 2011
Previous Registration Information
State Agency: ____________________________________________________________________
Business Address of State Agency (Physical): ___________________________________________
________________________________________________________________________________
Name and Title of State Agency’s Authorized Officer:
Mailing Address of State Agency’s Authorized Officer:
________________________________________________________________________________
Telephone No. of State Agency’s Authorized Officer: _____________________Fax:______________
E-Mail Address of State Agency’s Authorized Officer: ______________________________________
Amended Registration Information
Business Address of State Agency (Physical):____________________________________________
________________________________________________________________________________
Name and Title of State Agency’s Authorized Officer:
Mailing Address of State Agency’s Authorized Officer:
E-Mail Address of State Agency’s Authorized Officer: ______________________________________
Statement of Termination
I hereby terminate the authorization of _________________________ to act as a liaison on behalf
of ____________________________________________________________________________.
______________________________________________________
___________________
Signature of State Agency Authorized Officer
Date
Certification of Amendment
I hereby certify that all information disclosed in this “State Agency Amendment Statement” is true,
complete and correct in accordance with G.S. §120C-206(c).
______________________________________________________
___________________
Signature of State Agency Authorized Officer
Date
Preparer Information
_________________________________________________________________________________________________
Signature of Preparer
(If Other Than State Agency Authorized Officer)
Printed Name of Preparer
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