Authorization For Political Advertising In Above Newspaper Form

Authorization For Political Advertising In Above Newspaper Form - North Carolina

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 ____________

Authorization For Political Advertising In Above Newspaper Form - North Carolina