Free lobbyist reg. 09.p65 - Wyoming

Lobbyist Registration Form W.S. 28-7-101
This form can be accessed on the Secretary of State's website at: http://soswy.state.wy.us/Forms/Forms.aspx

Name of Lobbyist

_________________________________________________________ Last First MI _________________________________________________________ (Print/type your name exactly as you wish it to appear on your name tag)

Business/Home Address

___________________________________ Phone (___) __________ ___________________________________ Fax ___________________________________ (___) __________

E-mail Address

___________________________________

Name of organization employing this lobbyist ____________________________________________ Business Address ___________________________________ Phone (___) __________ ___________________________________ Fax ___________________________________ Name of organization employing this lobbyist ____________________________________________ Business Address ___________________________________ Phone (___) __________ ___________________________________ Fax ___________________________________ Name of organization employing this lobbyist ____________________________________________ Business Address ___________________________________ Phone (___) __________ ___________________________________ Fax ___________________________________ (___) __________ (___) __________ (___) __________

Signature required on reverse side

lobbyist reg. 09

For Office Use Only:
Nametag Entered

W. S. 28-7-101(b) states: "The secretary of state shall collect a registration fee of twenty-five dollars ($25.00) at time of registration, which shall be deposited with the state treasurer to be placed in the general fund. Any person who is not receiving or has no reasonable expectation of receiving expense reimbursement or compensation in excess of five hundred dollars ($500.00), or who shall receive no compensation beyond travel and per diem expenses for lobbying activities under this chapter shall pay a registration fee of five dollars ($5.00) to the secretary of state at the time of registration."

Registration Fee of ______ $25.00 ______ $5.00 is attached

Wyoming Lobbyist Rules state: "Lobbyists who are required to pay a required fee shall register with the Secretary of State within forty-eight (48) hours of commencing lobbyist activities."

W.S. 28-7-201(c): Lobbyist Activity Reports are due no later than June 30 for activities during the preceding year May 1st through April 30th.

This registration expires April 30 of each year.

I certify that I have read and understand the above information and, to the best of my knowledge and belief, the information I have provided is true, correct and complete.

_____________________________________ Lobbyist Signature

_________________________________ Date Signed

Applications can be mailed to: _____________ Secretary of State's Office Attn: Elections 200 W. 24th Street Cheyenne, WY 82002

Name of Lobbyist

_________________________________________________________ Last First MI

Name of organization employing this lobbyist ____________________________________________ Business Address ___________________________________ Phone (___) __________ ___________________________________ Fax ___________________________________ Name of organization employing this lobbyist ____________________________________________ Business Address ___________________________________ Phone (___) __________ ___________________________________ Fax ___________________________________ Name of organization employing this lobbyist ____________________________________________ Business Address ___________________________________ Phone (___) __________ ___________________________________ Fax ___________________________________ Name of organization employing this lobbyist ____________________________________________ Business Address ___________________________________ Phone (___) __________ ___________________________________ Fax ___________________________________ (___) __________ (___) __________ (___) __________ (___) __________