Lobbyist Registration

Office of the City Clerk
P.O. Box 1088
Austin, Texas 78767

                                                                    INSTRUCTIONS
Unless exempt under City Code 4-8-5, a person must register with the City Clerk if the person has done any of the following during a calendar quarter of the year: (1) Expended $200 or more for lobbying; (2) received compensation of $200 or more for lobbying; (3) received reimbursement of $200 or more for lobbying; (4) lobbied as the agent or employee of a person who performed one or more of the above listed actions. This registration must be filed annually with the City Clerk not later than two working days after becoming a lobbyist. The report must be signed under oath.

Registrant Information :	Last Name:
     	First Name:
     	Middle Initial:
 	
Street Address: 	     	
	City:      	State:      	Zip:      	
Contact Information:	Phone Number:
     	E-mail (optional): 
     	

As to each lobby employer (a person who compensates another person to lobby on any municipal question of interest to the person) on whose behalf the registrant will lobby, state the following: 

As to each lobby employer (a person who compensates another person to lobby on any municipal question of
interest to the person) on whose behalf the registrant will lobby, state the following:

Name of Business:	Business Address:	Nature of Business:	Municipal Question(s) in which the registrant will lobby: 	
     	     	     	     	
     	     	     	     	
*Additional pages in the back 

If the Registrant is an agent or employee of a lobbying entity (a corporation, association, firm, partnership, committee, club, organization, or group of persons who are voluntarily in a concert that is compensated by a lobby employer to lobby), state the following: 

Name of Entity:	Address of Entity:	Nature of Business:	
     	     	     	

STATE OF TEXAS
COUNTY OF TRAVIS

AFFIDAVIT

I swear or affirm under penalty of perjury that this Lobbyist Registration Form is true and correct and includes all information required to be reported by me pursuant to Section 4-8-6 of the Austin City Code of 2003 for the reporting period indicated.

__________________________
Signature of Affiant

SWORN TO AND SUBSCRIBED BEFORE ME by the said _______________________________,
on this the _______ day of _________________________, 200____, witness my hand and seal of office.

__________________________
Signature of Notary

(SEAL)

Name of Business:	Business Address:	Nature of Business:	Municipal Question(s) in which the registrant will lobby:	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
*Additional pages may be used if necessary