Lobbyist Registration Form - The Metropolitan Government Of Nashville And Davidson County

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THE METROPOLITAN GOVERNMENT OF NASHVILLE
AND DAVIDSON COUNTY
LOBBYIST REGISTRATION
1. DATE REGISTRATION SUBMITTED
2. NAME OF LOBBYIST
________________________________________________________________________________________________________________________________
3. LOBBYIST'S ADDRESS AND PHONE
________________________________________________________________________________________________________________________________
4. NAME OF CLIENT
________________________________________________________________________________________________________________________________
5. NATURE OF CLIENT'S BUSINESS
________________________________________________________________________________________________________________________________
6. NAME OF CLIENT REPRESENTATIVE
6.A. TITLE
________________________________________________________________________________________________________________________________
7. CLIENT'S ADDRESS AND PHONE
________________________________________________________________________________________________________________________________
8. IS LOBBYIST'S FEE CONTINGENT UPON SUCCESS?
Yes ___
No ___
If yes, is employment agreement in writing?
Yes ___
No ___
9. LIST GENERAL CATEGORIES OF SUBJECT MATTER ON WHICH REGISTRANT WILL LOBBY
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
10. TO BE SIGNED BY LOBBYIST (must be notarized)
I do solemnly swear that the information contained in this state-
Notary Seal
ment is true and that I have complied with all requirements of
the Lobbyist Registration and Disclosure Law.
SWORN TO AND SUBSCRIBED BEFORE ME IN THE COUNTY OF
___________________________________________________
DAVIDSON AND THE STATE OF TENNESSEE THIS_______ DAY OF
signature of lobbyist
_______________________________________19___________
____________________________________________________
notary public
____________________________________________________
date commission expires
________________________________________________________________________________________________________________________________
11. TO BE SIGNED BY CLIENT (must be notarized)
I do solemnly swear that the information contained in this state
ment is true and that I have authorized the above named person
to be a lobbyist on my behalf. I understand that I may be respon-
Notary Seal
sible for filing a lobbying activities report should the lobbyist fail
to file reports required under the Lobbyist Registration and
Disclosure Law.
SWORN TO AND SUBSCRIBED BEFORE ME IN THE COUNTY OF
___________________________________________________
DAVIDSON AND THE STATE OF TENNESSEE THIS_______ DAY OF
signature of client
_______________________________________19___________
____________________________________________________
notary public
____________________________________________________
date commission expires

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