2012-rLouisBagliettto l
City of Long Beach
LOBBYIST RENEWAL FORM RECEIVED
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LOC" , 0 CA
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INSTRUCTIONS 12 JAN W 9
1. Fill out form
2. Sign and date
3. File with the City Clerk by due date with payment enclosed, along with any applicable late
I fees.
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Long Beach City Clerk's Office
333 W. Ocean Blvd.
Long Beach, CA 90802
Tel. 562 570-6101
This is the Renewal Registration Report due January 15 for:
Lobbyist Name
Filer ID Number (1
Calendar Year Covered
Registration Fees: Persons subject to the registration requirements of this ordinance shall pay an annual
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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 $
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Payment Method: C sh Check
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Verification of Person Responsible for Report Preparation:
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Print Name: � ���nC.L�rt7� J�---
Title: Sle—
Address:
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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
knowledge the information contained herein is true and complete.
I certify under penalty of perjury under the laws of the State correct.
Date: (-A lSignature•
City of Long Beach Lobbyist Renewal Report Form—12/23/2010 Page 1 of 1
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