Newspaper Name:____________________________________ Date: ________________
AUTHORIZATION FOR POLITICAL ADVERTISING IN ABOVE NEWSPAPER
I, ___________________________________________, hereby authorize the publication of
advertisement(s) entitled or described as:
_____________________________________________________________________. I further certify
that I am authorized to place this advertisement in accordance with the Campaign
Reporting Act of the General Statutes of North Carolina.
Name of individual, committee, or entity making communication:
_____________________________________________________________________
Address of the individual, committee or entity making
communication:________________________________________________________________________
__________________________________________________________________
The advertising is for publication on the following date(s):
_____________________________________________________________________________.
Amount paid for advertising in this authorization: $_____________.
Check Number _________. Account listed as:______________________________.
NCGS § 163-278.39(a) provides the legend disclosure statement requirments that must be
included on advertisements subject to that statute. I have read the attached statute and
understand the requirements for the advertisement I am authorizing.
Please provide the legend/disclosure statement as it should appear on the advertisement:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
SIGNED ___________________________________________________________________
(Individual authorizing expenditure)
Title _______________________________________________________________________
Address ____________________________________________________________________
City __________________________ State ________ Zip ___________
If agency/public relations firm, please complete the following:
Name of Agency __________________________________________
Address _________________________________________________
City ______________________ State ________ Zip ____________