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Lobbyist Annual Disclosure Form

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Lobbyist Annual Disclosure Form

* Required Field

Your contact information

*First Name

*Last Name

Home Address

City

State

Zip Code

*Email

* Phone Number

Your Job Information

* Job Title

Business Address

City

State

Zip Code

* List all positions and time periods the Registered Lobbyist has held as an elected official, employee, or board member of a city, county or state.

Do you have Individuals, Business, Organizations or other Entities which you have authorized to lobby on your behalf?

Yes

Previous step

Employees or Agents

Employees or agents are individuals, businesses, organizations, or other entities which you have authorized to lobby on your behalf.

* First Name

* Last Name

Home Address

City

State

Zip Code

* Phone Number

* Email

* List all positions and time periods Employee/Agent 1 has held as an elected official, employee, or board member of a city, county or state.

Business Address

Street Number

City

State

Zip Code

* Add another Employee/Agent

Yes

Previous step

Employee/Agent

* First Name

* Last Name

Home Address

City

State

Zip Code

* Phone Number

* Email

* List all positions and time periods Employee/Agent 2 has held as an elected official, employee, or board member of a city, county or state.

Business Address

Street Number

City

State

Zip Code

Previous step

Do you have Individuals, Businesses, Organizations or other Entities which have compensated you to lobby on their behalf?

Yes

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Clients

* First Name

* Last Name

Street Number

City

State

Zip Code

* Phone Number

* Email

* Add Another Client?

Yes

* Provide a statement for all matters you have lobbied for this client in the past year or plan to lobby for in the future.

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Client

* First Name

* Last Name

Street Number

City

State

Zip Code

* Phone Number

* Email

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Sign Electronically

I have been provided with the electronic website address for the Cuyahoga County Ethics Law (http://code.cuyahogacounty.us/en-US/CCRC-T4.aspx)
I agree I have read and I understand the pertinent sections of the Cuyahoga County Ethics Law
I agree to follow the pertinent sections of the Cuyahoga County Ethics Law
I acknowledge that I am responsible for periodically reviewing the Cuyahoga County Ethics Law to stay abreast of any pertinent amendments

Electronic Signature

Date

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