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City of Long Beach
RECEIVED
LOBBYIST RENEWAL FORM CITY CLI:RK
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INSTRUCTIONS
1. Fill out form r
2. Sign and date
3. File with the City Clerk by due date with payment enclosed, along with any applicable late
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fees.
Long Beach City Clerk's Office
333 W. Ocean Blvd.
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Long Beach, CA 90802
Tel. 562 570-6101
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This is the Renewal Registration Report due January 15 for:
Lobbyist Name
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� Filer ID Number oI I
Calendar Year Covered aO 1 2
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Registration Fees: Persons subject to the registration requirements of this ordinance shall pay an annual
fee of one hundred dollars($100.00).The applicable fee is due at the time of registration renewal. Payment
will be deemed delinquent thereafter.A fine of twenty-five dollars ($25.00)per day for delinquent fees,up
to a maximum of five hundred dollars($500.00),will be assessed.
Annual Registration Fee is$100.00
Late Fee Total(if applicable) $
Total submitted $
Payment Method: Cash Check_�� IBJ/ G.• ���uE✓ �
Verification of Person Responsible for Report Preparation:
Print Name: L) F
Title:l 125 t pEt-�r
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I have used all reasonable diligence in preparing this report. I have reviewed all the sections and to the best of my F
knowledge the information contained herein is true and complete.
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I certify under penalty of perjury under the laws of the State
Date: /13�I 2 Signature:
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City of Long Beach Lobbyist Renewal Report Form—12/23/2010 Page 1 of 1
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