Free Lobbyist Registration Form - Virginia

SECRETARY OF THE COMMONWEALTH LOBBYIST REGISTRATION FORM (Rev. 12/06) Please send the original and a copy with a $50.00 registration fee, made Payable to the Treasurer of Virginia to: Secretary of the Commonwealth Attn: Lobbyist Specialist 1111 E. Broad St. 4th Floor Richmond, Virginia 23219 (1) PRINCIPAL: __________________________________________________________________________________________ FOR OFFICE USE ONLY Principal Notification Date _________ Date Received __________ Fee Paid: Check # _______ Cash______

(1a) What type of business is the principal engaged in: __________________________________________________________________________________________________________ Officer of Principal authorizing your employment as a lobbyist, or to whom your expenditures will be reported. The same name may not appear in items 2 and 5 of this form. (2) Name: _______________________________________________________________________________________________ (2a) Business Address: _____________________________________________________________________________________ (2b) Business Telephone: ___________________________________________________________________________________ Officer of Principal who will retain ALL records, in behalf of the principal, with respect to your lobbying activities for their organization. If records are physically stored in another location, please so indicate in the space provided by item 3c. (3) Name: _______________________________________________________________________________________________ (3a) Business Address: _____________________________________________________________________________________ (3b) Business Telephone: ___________________________________________________________________________________ (3c) Business Address/Telephone number of location where records are stored: __________________________________________________________________________________________________ __________________________________________________________________________________________________ (4) Please list the full name(s), business address(es), and telephone number(s) of all other individual(s) that are registered to lobby in behalf of the PRINCIPAL listed in item 1 of your registration form.

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SECRETARY OF THE COMMONWEALTH LOBBYIST'S REGISTRATION Page Two

(5) LOBBYIST: ___________________________________________________________________________________________ (5a) Business Address: _____________________________________________________________________________________ (5b) Business Telephone: ___________________________________________________________________________________ (5c) E-Mail Address: _____________________________________________________________________________________ Individual who will retain ALL records, on behalf of the lobbyist, with respect to your lobbying activities for the afore-designated principal. If records are physically stored in another location, please so indicate in the space provided in item 6c. (6) Name: _______________________________________________________________________________________________ (6a) Business Address: _____________________________________________________________________________________ (6b) Business Telephone: ___________________________________________________________________________________ (6c) Business Address/Telephone number of location where records are stored: __________________________________________________________________________________________________ __________________________________________________________________________________________________ (7) Matters and purpose for which you expect to lobby: (be as specific as possible in this response) __________________________________________________________________________________________________ __________________________________________________________________________________________________ (8) As a lobbyist, you are: (check one) Employed (Lobbyist is on payroll of principal) Retained (Lobbyist is not on payroll of principal, but is compensated) Not Compensated (Lobbyist is not compensated, but expenses may be reimbursed) (9) If you are employed either part-time or full-time by the principal, please give your job title: __________________________________________________________________________________________________ I, the undersigned lobbyist, do state that the information furnished on this registration statement and on any and all accompanying statements attached thereto, is to the best of my knowledge and belief, complete and accurate. Date: ____________________________ Lobbyist's Signature: _____________________________________________________