Lobbyist Registration Form - Minnesota Campaign Finance And Public Disclosure Board Page 2
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1
2Attach additional sheets, if necessary, to report all information required in categories below
Lobbyist Reporting Status
You must select only one of the following three reporting options:
I will report my lobbying disbursements directly to the Board.
I authorize the following lobbyist to report my lobbying disbursements for this association:
:
:
Name of lobbyist
Lobbyist registration #
I am authorized to report for the following registered lobbyists for this association:
Name(s) of lobbyist(s) I will be reporting for:
Lobbyist registration number
_
_
_
_
_
_
Designated Lobbyist Status
I am also the designated lobbyist for this association and will include in my report to the Board the lobbying disbursements
made by the association or individual I represent.
Subject(s) on which lobbyist expects to lobby and kind of action seeking to influence
√
Check (
) kind of action for each subject listed
General description of subject(s)
Legislative
Administrative
Metropolitan
action
action
Governmental
(“General legislation” is not a subject)
Unit action
Officers and Directors of Association Represented
(Required)
The first name and telephone number listed below should be the individual responsible for filing the Annual Report of Lobbyist Principal.
Name and Title of Officer
Address
Telephone
Certification
I,
, certify that the information contained on this form is
(print or type name of lobbyist)
complete, true, and correct.
Signature of lobbyist
Date
Any person who signs and certifies to be true a report or statement which the person knows contains false information, or
who knowingly omits required information, is subject to a civil penalty imposed by the Board of up to $3,000 and is subject to
criminal prosecution for a gross misdemeanor.
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