Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711-2070 (512) 463-5800 (TDD 1-800-735-2989) REPRESENTATION BEFORE STATE AGENCIES Certain individuals who appear before a state agency or contact in person an officer or employee of the state agency on behalf of an individual, firm, partnership, corporation, or association about a matter before the agency must register with that agency in compliance with Tex. Gov't Code Ch. 2004. Account No. FORM REP OFFICE USE ONLY Date Received 1 Name of Registrant 2 Address of Registrant ADDRESS / PO BOX APT / SUITE # Date Processed CITY STATE ZIP CODE Date Imaged 3 Name of Entity or Individual Registrant Represents 4 Address of Entity or Individual Registrant Represents ADDRESS / PO BOX APT / SUITE # CITY STATE ZIP CODE 5 Compensation Have you received or do you expect to received any money, thing of value, or financial benefit for the appearance before or contact with this state agency or an officer or employee of this state agency? Yes No ARE YOU REQUIRED TO REGISTER? The following questions will help you determine whether you are required to register. Yes No Are you appearing before the state agency or contacting an officer or employee of the agency in person? Is the contact on behalf of an individual, firm, partnership, corporation, or association about a matter before the state agency? Yes No Yes No Is the contact being made in order to attempt to influence the action of an officer or employee of the state agency? Is the contact concerning a matter that is not on file with the state agency as a pleading or other instrument that discloses your representation? Are you receiving compensation or any thing of value for the contact? Yes No Yes No If you answered "NO" to any of these questions, you are not required to register. Also, if you are making an appearance and participating at a public hearing or if you are an officer or employee of a state agency and are making contact regarding an interagency matter, you are exempt from registering. www.ethics.state.tx.us Revised 03/16/1998 American LegalNet, Inc. www.FormsWorkFlow.com