Mail-In

Walk-In

Registration for year

Employer Name

Business Interest

Explanation

Prefix

First Name

Middle Name

Last Name

Suffix

Title

Lobbyist	Phone	Email	Date Employed	Paid Registration	Date Terminated	Lobbyist Registration Status	You will Pay Registration Fee	Actions
	Phone	Email						Edit Remove Terminate

Total Registration Fee Owed: ${{lmsClientRegistration.getEmployerRegistrationFeeAmountTotal()}}

Registration Fee to be Paid: ${{lmsClientRegistration.getEmployerRegistrationFeeAmount()}}

User	Email	Phone	Actions
	Email	Phone	Edit Remove

I hereby certify under the penalty of law that all the information provided is true, complete, and correct to best of my knowledge.

Electronic Signature of Employer, Agent, or Authorized Representative

Title

Date of Signature

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