Form R - Lobbyist'S Registration Form - Office Of The Mississippi Secretary Of State
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OFFICE OF THE MISSISSIPPI SECRETARY OF STATE
FORM
ERIC CLARK, Secretary of State,
401 Mississippi Street, Post Office Box 136, Jackson, Mississippi 39205-0136
Lobbyist’s Registration Form
For office use only. Do not write in this space.
INSTRUCTIONS
:
1. Type or print information. Complete all information.
2. Lobbyist and lobbyist's client must sign form.
3. Mail or deliver completed form and $25.00 fee to:
Mississippi Secretary of State, Attn: LOBBYIST REGISTRATION
401 Mississippi Street, Post Office Box 136
Jackson, Mississippi 39205-0136
(601) 359-6353 [phone] (601) 359-1499 [fax]
Authorized by
(Incomplete forms or forms submitted without signatures or without fee will be returned. All
Certificate Number
lobbyists are required to submit an Annual, Mid-Session and End-of-Session Report during
the Lobbyist cycle.)
SECTION A: Lobbyist Information
1.
LOBBYIST’S FULL NAME
2.
Permanent mailing address
City
State
Zip
3.
Permanent Phone
(
)
4.
Temporary Phone
(
)
5.
Fax
(
)
6.
E-mail/Other Phone
SECTION B: Lobbyist’s Client Information
7.
Full name of LOBBYIST'S CLIENT
8.
Permanent mailing address
City
State
Zip
9.
Permanent physical address
City
State
Zip
10. Phone
11. Fax
12. E-mail/Other Phone
(
)
(
)
14. Contact Person and Title
13. Federal Tax ID Number
15. Full name and title of Principals (Officers, Partners and/or Directors). Attach separate sheet if necessary.
Name
Title
________________________________________________
__________________________________________________
________________________________________________
__________________________________________________
________________________________________________
__________________________________________________
16. State the exact nature of business for this lobbyist's client. (What does this client do?)
__________________________________________________________________________________________________________
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