Fill and Sign the Cdl Medical Certificate Form

APOC GROUP LOBBYIST REGISTRATION FORM FOR LEGISLATIVE FLY-INS MAIL TO: PHYSICAL DELIVERY ADDRESS: AK Public Offices Commission PO Box 110222 Juneau, Alaska 99811-0222 Phone: 907-465-4864 In-State Toll Free: 866-465-4864 Court Plaza Building 240 Main Street, Suite 500 Juneau, Alaska 99801 Fax: 907 465-4832 (2 AAC 50.550) 1) 2) 3) 4) INSTRUCTIONS FOR COMPLETING A GROUP LOBBYIST REGISTRATION This group lobbyist registration form is to be used only for representational lobbyists whose expenses for influencing legislative or administrative action are being reimbursed. Representational lobbyists may not receive a salary, fee, retainer or economic consideration of any type to influence legislative or administrative action. AS 24.45.041(a) and 2 AAC 50.550. If you are being paid to communicate directly with public officials for the purpose of influencing legislative or administrative action, you are not a representational lobbyist and must register on APOC registration form 24-1. AS 24.45.041(b). Each group lobbyist registration may only list representational lobbyists whose expenses are being reimbursed by a single entity. A separate group registration statement must be completed by each entity reimbursing expenses for multiple representational lobbyists. There is no registration fee for registering as a representational lobbyist AS 24.45.041(g). Representational lobbyists are not required to file lobbyist reports with APOC, but the entity reimbursing their expenditure is required to file with APOC. 2 AAC 50.555(b). GENERAL INFORMATION (PLEASE PRINT OR TYPE) Representational Lobbyist Information (Printed Name and Signature) 1. ____________________________________________________________ 2. ____________________________________________________________ 3. ____________________________________________________________ 4. ____________________________________________________________ 5. ____________________________________________________________ 6. ____________________________________________________________ 7. ____________________________________________________________ 8. ____________________________________________________________ 9. ____________________________________________________________ 10. ____________________________________________________________ Attach Separate Name/Signature Sheet as necessary 1 APOC GROUP LOBBYIST REGISTRATION FORM FOR LEGISLATIVE FLY-INS Representational Lobbyist Verification/Certification Pursuant to AS 24.45.041 and 2 AAC 50.550, the lobbyists’ signatures on this group registration form affirm their agreement that they: 1. Are not being paid a salary, fee, retainer or economic consideration of any type to influence legislative or administrative action 2. Are only receiving reimbursement for their expenses to influence legislative or administrative action 3. Are being reimbursed for their expenses by the employer listed below Lobbying Interests Describe the SUBJECTS OR MATTERS on which you will lobby for the employer or entity reimbursing your expenses: _______________________________________________________________________ _______________________________________________________________________ Indicate the month and day the individuals listed on this group registration will start lobbying:____________________________________ Employer/Reimbursing Entity Information Business Name: ____________________________________________________ Contact Person: ____________________________________________________ Mailing Address: ___________________________________________________ _________________________________________________________________ Phone: _________________Fax:________________E-mail:_________________ Employer/Reimbursing Entity Verification The signature below certifies that this group representational lobbyist registration is true, complete, and correct, and that the lobbyists named on this group registration are being reimbursed for their expenses by our agency to lobby. By signing, I further understand that our agency is required to file reports with APOC per AS 24.45.061, 2 AAC 50.555(b) and 2 AAC 50.575. ________________________________________________ Employer’s Signature ____________ Date ________________________________________________ Type or Print Name _____________ Title Attach Separate Name/Signature Sheet as necessary 2