Joint Legislative Ethics Committee 50 West Broad Street, Suite 1308 Columbus, Ohio 43215-5908 (614) 728-5100 www.jlec-olig.state.oh.us Official Use Only - Do not alter the above barcode EXECUTIVE AGENCY LOBBYIST/EMPLOYER INITIAL REGISTRATION STATEMENT This statement must be filed with the Office of the Legislative Inspector General within ten (10) days of engagement. Please read instructions and review Section 121.62, Ohio Revised Code, prior to filing. There is a $25.00 fee for this filing. Check or money order only made payable to "JLEC". Upon termination of this engagement, there is an affirmative duty to notify the Office of the Legislative Inspector General within thirty (30) days (the form may be obtained from the OLIG). ANY PERSON WHO KNOWINGLY FILES A FALSE STATEMENT IS GUILTY OF FALSIFICATION UNDER SECTION 2921.13 OF THE OHIO REVISED CODE, WHICH IS A MISDEMEANOR OF THE FIRST DEGREE. FORM #121.62-A&E $25.00 FILING FEE (check or money order only) I. EXECUTIVE AGENCY LOBBYIST INFORMATION 1. Full Name 2. Business Address ____________________________ Street Suite number _________________________________________________________________________________________________ City State Zip(+4) 3. Telephone Number ______________________ Email _________________________________ 4. Date of Engagement as Executive Agency Lobbyist II. Employer Information 1. Full name of company/org.______________________________________________ 2. Type of Industry______________________________________________________ 3. Business Address____________________________________________________ Street Suite Number ___________________________________________________________________ City 4. State Zip(+4) Contact Person Located at Employer’s Address_____________________________ Telephone number of contact person _____________________________________ American LegalNet, Inc. www.FormsWorkflow.com III. Brief description of the Executive Agency Decision(s) to which Executive Agency Lobbyist's engagement relates: IV. Categorical listing of offices of Elected Executive Officials, Departments or Executive Agencies to which the engagement relates: (Please check all that are applicable): Offices of Elected Executives Governor Executive Agency Departments, Boards, Commission (Please see and check attached list) Lieutenant Governor Secretary of State Auditor of State Treasurer of State Attorney General CERTIFICATION: THE UNDERSIGNED HEREBY CERTIFY THAT ALL REASONABLE EFFORTS AND DUE DILIGENCE HAVE BEEN UNDERTAKEN IN THE PREPARATION AND COMPLETION OF THIS STATEMENT AND THAT THE CONTENTS ARE TRUE AND ACCURATE TO THE BEST OF HIS OR HER KNOWLEDGE. ALL SIGNATURES MUST BE ORIGINAL AND SIGNED PERSONALLY BY THE NAMED INDIVIDUAL. Type or Print Name of Executive Agency Lobbyist Signature of Executive Agency Lobbyist Date Type or Print Name of Employer Representative Signature for Employer Title Date Rev. 9/03 American LegalNet, Inc. www.FormsWorkflow.com Please check all in which Executive Agency Lobbying is likely to occur. Note: Please be advised that the list may not include all entities qualifying as executive agencies as defined by R.C. 121.60(F). Executive Agency Departments: _____ Bureau of Workers’ Compensation _____ Department of Administrative Services _____ Department of Aging _____ Department of Agriculture _____ Department of Alcohol and Drug Addiction Services _____ Department of Commerce _____ Department of Development _____ Department of Education _____ Department of Health _____ Department of Insurance _____ Department of Job & Family Services _____ Department of Mental Health _____ Department of Mental Retardation and Developmental Disabilities _____ Department of Natural Resources _____ Department of Public Safety _____ Department of Rehabilitation & Correction _____ Department of Taxation _____ Department of Transportation _____ Department of Youth Services _____ Environmental Protection Agency _____ Industrial Commission _____ Lottery Commission _____ Office of Budget & Management _____ Office of Criminal Justice Services Boards & Commissions: _____ Administrator, Interstate Compact on Mental Health _____ Administrator, Interstate Compact on Placement of Children _____ Advisory Board of Governor's Office of FaithBased and Community Initiatives _____ Advisory Boards to the EPA for Air Pollution _____ Advisory Boards to the EPA for Water Pollution _____ Advisory Committee of the State Veterinary Medical Licensing Board _____ Advisory Committee on Livestock Exhibitions _____ Advisory Council on Amusement Ride Safety _____ Advisory Board of Directors for Prison Labor _____ Advisory Council for Each Wild, Scenic, or Recreational River Area _____ Advisory Councils or Boards for State Departments _____ Advisory Group to the Ohio Water Resources Council _____ Alzheimer's Disease Task Force _____ AMBER Alert Advisory Committee _____ Apprenticeship Council _____ Armory Board of Control _____ Automated Title Processing Board _____ Banking Commission _____ Board of Directors of the Ohio Health Reinsurance Program _____ Board of Speech Pathology and Audiology _____ Board of Tax Appeals _____ Board of Voting Machine Examiners _____ Brain Injury Advisory Committee _____ Capitol Square Review and Advisory Board _____ Child Support Guideline Advisory Council _____ Children's Trust Fund Board _____ Citizens Advisory Committee (BMV) _____ Clean Ohio Trail Advisory Board _____ Coastal Resources Advisory Council _____ Commission on African-American Males _____ Commission on Hispanic-Latino Affairs _____ Commission on Minority Health _____ Committee on Prescriptive Governance _____ Commodity Advisory Commission _____ Community MR/DD Trust Fund Advisory Council _____ Community Oversight Council _____ Compassionate Care Task Force _____ Consumer Advisory Committee to the Rehabilitation Services Commission _____ Continuing Education Committee (for Sheriffs) _____ Controlling Board _____ Coordinating Committee, Agricultural Commodity Marketing Programs _____ Council on Alcohol and Drug Addiction Services _____ Council on Unreclaimed Strip Mined Lands _____ Council to Advise on Establishment & Implementation of the Birth Defects Information System _____ County Sheriffs' Standard Car-Marking and Uniform Commission _____ Credit Union Council _____ Criminal Sentencing Advisory Committee _____ Day-Care Advisory Council _____ Dentist Loan Repayment Advisory Board _____ Development Financing Advisory Council _____ Education Commission of the States (Interstate Compact for Education) _____ Educational Telecommunications Network Commission _____ Electrical Safety Inspector Advisory Committee _____ Emergency Response Commission _____ Engineering Experiment Station Advisory Committee _____ Environmental Education Council _____ Environmental Review Appeals Commission _____ EPA Advisory Boards or Councils _____ Farmland Preservation Advisory Board _____ Financial Planning & Supervision Commission for Municipal Corporation, County, or Township _____ Financial Planning & Supervision Commission for School District _____ Forestry Advisory Council _____ Governance Authority for a State University or College _____ Governor's Advisory Council on Physical Fitness, Wellness, & Sports _____ Governor's Council on People with Disabilities _____ Governor's Residence Advisory Commission _____ Great Lakes Commission (Great Lakes Basin Compact) _____ Gubernatorial Transition Committee _____ Head Start Partnership Study Council Section _____ Hemophilia Advisory Subcommittee _____ Housing Trust Fund Advisory Committee _____ Industrial Commission Nominating Council _____ Industrial Technology and Enterprise Advisory Council _____ Infant Hearing Screening Subcommittee _____ Insurance Agent Education Advisory Council _____ Interagency Council on Hispanic/Latino Affairs _____ Interstate Mining Commission (Interstate Mining Compact) _____ Interstate Rail Passenger Advisory Council _____ Joint Council on MR/DD _____ Joint Select Committee on Volume Cap _____ Labor-Management Government Advisory Council _____ Legal Rights Service Commission _____ Legislative Task Force on Redistricting, Reapportionment, and Demographic Research _____ Maternal and Child Health Council _____ Medically Handicapped Children's Medical Advisory Council _____ Midwest Interstate Passenger Rail Compact Commission (Ohio members) American LegalNet, Inc. www.FormsWorkflow.com _____ Military Activation Task Force _____ Milk Sanitation Board _____ Mine Subsidence Insurance Governing Board _____ Minority Development Financing Board _____ Multi-Agency Radio Communications Systems Steering Committee _____ Multidisciplinary Council _____ Muskingum River Advisory Council _____ National Museum of Afro-American History and Culture Planning Committee _____ Nursing Facility Reimbursement Study Council _____ Ohio Advisory Council for the Aging _____ Ohio Aerospace & Defense Advisory Council _____ Ohio Air Quality Development Authority _____ Ohio Arts Council _____ Ohio Board of Motor Vehicle Collision Repair Regis. _____ Ohio Business Gateway Steering Committee _____ Ohio Cemetery Dispute Resolution Commission _____ Ohio Civil Rights Commission Advisory Agencies and Conciliation Councils _____ Ohio Commercial Insurance Joint Underwriting Association Board of Governors _____ Ohio Commercial Market Assistance Plan Executive Committee _____ Ohio Commission on Dispute Resolution and Conflict Management _____ Ohio Commission to Reform Medicaid Section _____ Ohio Community Service Council _____ Ohio Council for Interstate Adult Offender Supervision _____ Ohio Cultural Facilities Commission _____ Ohio Developmental Disabilities Council _____ Ohio Educational Telecommunications Network Commission _____ Ohio Ethics Commission _____ Ohio Expositions Commission _____ Ohio Family and Children First Cabinet Council _____ Ohio Geology Advisory Council _____ Ohio Grape Industries Committee _____ Ohio Hepatitis C Advisory Commission _____ Ohio Historic Site Preservation Advisory Board _____ Ohio Historical Society Board of Trustees _____ Ohio Judicial Conference _____ Ohio Lake Erie Commission _____ Ohio Medical Malpractice Commission _____ Ohio Medical Quality Foundation _____ Ohio Parks and Recreation Council _____ Ohio Peace Officer Training Commission _____ Ohio Public Defender Commission _____ Ohio Public Library Information Network Board _____ Ohio Public Works Commission _____ Ohio Quarter Horse Development Commission _____ Ohio SchoolNet Commission _____ Ohio Small Government Capital Improvements Commission _____ Ohio Soil and Water Conservation Commission _____ Ohio Standardbred Development Commission _____ Ohio Steel Industry Advisory Council _____ Ohio Teacher Education and Licensure Advisory Council _____ Ohio Thoroughbred Racing Advisory Committee _____ Ohio Tuition Trust Authority _____ Ohio University College of Osteopathic Medicine Advisory Committee _____ Ohio Vendors Representative Committee _____ Ohio War Orphans Scholarship Board _____ Ohio Water Advisory Council _____ Ohio Water Resources Council _____ Ohioana Library Association _____ Oil and Gas Commission _____ Operating Committee, Agricultural Commodity Marketing Programs _____ Organized Crime Investigations Commission _____ Parole Board _____ Petroleum Underground Storage Tank Release Compensation Board _____ Pharmacy and Therapeutics Committee of the Department of Job and Family Services _____ Physician Loan Repayment Advisory Board _____ Power Siting Board _____ Prequalification Review Board _____ Private Water Systems Advisory Council _____ Public Employment Risk Reduction Advisory Commission _____ Public Health Council _____ Public Utilities Commission Nominating Council _____ Public Utility Property Tax Study Committee _____ Radiation Advisory Council _____ Reclamation Commission _____ Recreation and Resources Commission _____ Recycling and Litter Prevention Advisory Council _____ Rehabilitation Services Commission Consumer Advisory Committee _____ Release Authority of Department of Youth Services _____ Savings & Loans Associations & Savings Banks Board _____ Schools and Ministerial Lands Divestiture Committee _____ Second Chance Trust Fund Advisory Committee _____ Self-Insuring Employers Evaluation Board _____ Services Committee of the Workers' Compensation System _____ Small Business Stationary Source Technical and Environmental Compliance Assistance Council _____ Solid Waste Management Advisory Council _____ State Agency Coordinating Group _____ State Board of Deposit _____ State Board of Education _____ State Board of Emergency Medical Services Subcommittees _____ State Council of Uniform State Laws _____ State Comm. for the Purchase of Products & Services Provided by Persons with Severe Disabilit _____ State Criminal Sentencing Commission _____ State Employment Relations Board _____ State Fire Commission _____ State Racing Commission _____ State Victims Assistance Advisory Committee _____ Student Tuition Recovery Authority _____ Tax Credit Authority _____ Technical Advisory Comm. to Assist the Director of the Ohio Coal Development Office Technical Advisory Council on Oil and Gas _____ Transportation Review Advisory Council _____ Tobacco Use and Prevention and Control Foundation _____ Unemployment Compensation Review Commission _____ Unemployment Compensation Advisory Council _____ Utility Radiological Safety Board _____ Vehicle Management Commission _____ Veterans Advisory Committee _____ Volunteer Fire Fighters' Dependents Fund Boards (Private and Public) _____ Water and Sewer Commission _____ Waterways Safety Council _____ Wildlife Council _____ Workers' Compensation System Oversight Commission _____ Workers' Compensation Oversight Commission Nominating Committee Other____________________________________________ American LegalNet, Inc. www.FormsWorkflow.com