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* 1. Name

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* 2. Date of meeting

Date

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* 3. Municipality

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* 4. Registering

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* 5. If you register to speak or have indicated you are available for information, you will be called when it is your turn (or information is needed from those registering availability for information only).  Please indicate the best phone number to be called at when it is time to speak.  NOTE: If you registered in support or opposition plelase enter N/A in the answer box.

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* 6. Item #/Petition/CUP# or Subject

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* 7. On this occasion, are you officially representing an organization or a person other than yourself?

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* 8. Name, address and telephone number of each person or organization you are representing:

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* 9. Are you being paid for your representation or appearing incidental to your other paid duties for this person or organization?

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* 10. Are you an elected official who is appearing solely on behalf of your office or for your municipality or other governmental body?

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* 11. Has or will the person or organization you represent spend more than $500 on county lobbying activities during the current reporting period? (A reporting period is January to June, or July to December.)

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* 12. Do you anticipate making more than two contacts with the County Board supervisors other than at public  hearings or meetings?

Do not count contacts with the County Board supervisor who represents the district in which you reside.

If you checked "NO" to questions 11 and 12 above, STOP; you do not need to complete the rest of this form. However, if you do make more than 2 contacts at a later date, you must then contact the County Clerk's office to file a form indicating such activity. You must also sign this form. If you checked "YES" to either question at this time, go on to the next question.

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* 13. If you answered "YES" to question 12, do you understand that if the person or organization you represent spends more than $500 during the current reporting period, you must file a financial disclosure statement with the County Clerk?

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