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 LEGISLATIVE AGENT/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 101.72, 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. $25.00 FILING FEE FORM #101.72-A&E (check or money order only) I. LEGISLATIVE AGENT INFORMATION 1. Full Name 2. Business Address Street City Suite number State Zip(+4) 3. 4. II. Telephone Number __________________________ Email _________________________ Date of Engagement as Legislative Agent _____________________________________ EMPLOYER INFORMATION 1. Full name of company/organization 2. Type of Industry 3. Mailing Address Street City 4. Suite Number 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 type of legislation to which Legislative Agent's engagement relates: IV. Categorical listing of principal business or activity of Employer, please check all that are applicable: Agriculture Environment Retail/Commercial Alcohol/Tobacco Financial Institutions/Consumer Finance Arts/Entertainment Medical/Hospitals/Health Care Service Business Social Svs./Human Svs. Communications/Media Insurance Science and Technology Contractors/Construction Labor/Labor Organizations State Employees County/Local Government Legal State Government Education Manufacturer Transportation ________Electronic Commerce Public Interest _______ Trade Association Real Estate/Housing Other _______________________ Energy/Utilities V. 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 Legislative Agent Signature of Legislative Agent Date Type or Print Name of Employer Representative Signature for Employer Title Date VI. I AM A STATE EMPLOYEE AND NOT REQUIRED TO PAY THE $25 REGISTRATION FEE. PLEASE INITIAL IF APPLICABLE _______ American LegalNet, Inc. www.FormsWorkflow.com