Form R - Lobbyist'S Registration Form
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1
2R
OFFICE OF THE MISSISSIPPI SECRETARY OF STATE, Eric Clark
FORM
Lobbyist’s Registration Form
For office use only. Do not write in
this space.
Faxed reports must be followed by originals.
INSTRUCTIONS
Please - no copies and no staples.
:
1. Complete all information.
How to locate forms on our
2. Lobbyist and lobbyist's client must sign form.
website
3. Mail or deliver completed form and $25.00 fee to:
Elections
Lobbying
Mississippi Secretary of State
Lobbying Forms Library
Attn: LOBBYING
Logged in by / Date
“R” – Registration
Physical : 401 Mississippi Street
“E” – Mid Session
Jackson, Mississippi 39201
“E” – End-of-Session
Mailing: Post Office Box 136
Lobbying Year
“A” – Lobbyist Annual Report
Jackson, Mississippi 39205-0136
“C” – Client Annual Report
(601) 359-6353 [phone] (601) 359-1499 [fax]
Begin:
Lobbying Beginning
Follow directions for extensions
(No Earlier -Jan. 1)
(1) Lobbyists who register on or before February. 25
th
must file a Mid-Session “E” and End-of-
Lobbying Ending
th
Session “E”. (2) Lobbyists who register from February, 26
, through sine die must file an End-
End:
(No Later- Dec.
of-Session “E”. (3) All Lobbyists and Clients must file an Annual Report – “A” Lobbyist/ “C” Client.
st
31
)
Lobbyists/Clients must notify our office if there are changes of addresses or phone
Certificate No. #
numbers. Write name of Client out in full. Do not abbreviate.
SECTION A: Lobbyist Information
1.
Lobbyist’s Full Name
2.
Occupation
3.
Physical Address (required)
City/Country
State
Zip
4.
Mailing Address
City/Country
State
Zip
5.
Daytime Phone (
)
6.
Cell Phone (
)
7.
Fax (
)
8.
E-mail
SECTION B: Lobbyist’s Client Information
9.
Full Name of Lobbyist’s Client
10. Physical Address (required)
City
State
Zip
11. Mailing Address
City
State
Zip
12. Phone (
)
13. Fax (
)
14. E-mail
16. Contact Person and Title
15. Federal Tax ID Number
□
□
17. Is client an agency of the state?
Yes
No
18. Full name and title of Principals (Officers, Partners and/or Directors). Attach separate sheet if necessary.
Name
Title
________________________________________________
_______________________________________________
________________________________________________
__________________________________________________
19. State the exact nature of business for this lobbyist's client.
Form R [rev. July-05]
Page 1 of 2
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