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OFFICE OF <br /> <br />THE COUNTY CLERK <br /> <br />25 Aupuni Street, Room 209 <br /> <br />Hilo, Hawai‘i 96720 <br /> <br />Telephone: (808) 961-8255 <br /> <br />LOBBYIST REGISTRATION FORM <br />You must file this form with the Office of the County Clerk if you are an individual who is engaged for pay or other <br />consideration and spends more than five hours lobbying in any month or more than $275 in any six month period. <br />(Type or Print Clearly) <br />NAME Last First Middle <br />MAILING ADDRESS Street City State Zip Code <br />TELEPHONE NUMBER NAME OF PERSON OR ORGANIZATION YOU LOBBY FOR (DO NOT ABBREVIATE) <br />MAILING ADDRESS Street City State Zip Code <br />EMPLOYEE ORGANIZATION <br />MAILING ADDRESS Street City State Zip Code <br />DESCRIPTION OF SUBJECTS UPON WHICH YOU EXPECT TO LOBBY <br /> Economic Development: Government-wide support: Employment: <br />Other: (Please indicate <br />government financing, taxation, work opportunity, working below) <br />commerce and industry, trade <br />and finance, tourism, revenue, appropriation, personnel conditions, compensation, <br />agricultureservices, employee funds unemployment and disability <br />compensation, vocational <br />rehabilitation <br /> Public safety: <br /> Transportation: <br />law enforcement and corrections, <br /> Environmental protection: <br />air, water, and land transportation <br />safety from physical disasters <br />pollution control, <br />facilities and services <br />environmental preservation and <br />enhancement <br /> Individual rights: Social Problems: <br />consumer protection, business and Social services, public assistance, <br /> of housing <br />Culture and recreation: professional regulation <br />cultural history and events, services, legal assistance <br />recreational activities <br />CERTIFICATION OF LOBBYIST <br />I hereby certify that the information furnished above is, to the best of my knowledge, correct and complete. <br />________________________________________________ ___________________________________ <br /> (Signature of Lobbyist) (Date) <br />AUTHORIZATION TO LOBBY <br />NAME TITLE OF AUTHORIZING OFFICER OR PERSON REPRESENTED <br />NAME OF ORGANIZATION (if applicable) <br />ADDRESS OF ORGANIZATION OR PERSON Street City State Zip Code <br />I hereby authorize the above-named person to engage in lobbying activities on behalf of the undersigned <br />. <br />(Signature of Authorizing Officer of Person Represented) (Date) <br />05/09 <br /> <br />