Fillable Change or Cancellation of Lobbyist Registration Suwannee River (Suwannee River Water Management District)

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Change or Cancellation of Lobbyist Registration Suwannee River (Suwannee River Water Management District)

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Change or Cancellation of Lobbyist Registration
Suwannee River Water Management District
If you have any changes, you must notify the SRWMD’s Contacts and procurement Coordinator in writing within 15 days. Type or
print clearly
the
name of the lobbyist and the principal represented as they are shown on the lobbyist registration form for the Suwannee River Water Management
District.
Change or cancellation is effective upon receipt by the SRWMD.
Name of Lobbyist ___________________________________________________________________________________
Last Name First Name MI
Lobbyist’s Mailing Address ___________________________________________________________________________________
___________________________________________________________________________________
CHANGE Request:
Lobbyist’s Name ___________________________________________________________________________________
Lobbyist’s Business Address ___________________________________________________________________________________
Lobbyist’s Phone Number ___________________________________________________________________________________
Principal’s Business Address ___________________________________________________________________________________
(Include the
name
of the Principal.)
Principal’s Phone Number ___________________________________________________________________________________
UpdatedDecember2014
Extent of any direct business association or partnership with SRWMD
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
NAICS six-digit code _B_______
_________
Lobbying Firm’s Name ___________________________________________________________________________________
Lobbying Firm’s Address ___________________________________________________________________________________
Lobbying Firm’s Phone Number ___________________________________________________________________________________
CANCELLATION Request:
Name of Principal to be cancelled ___________________________________________________________________________________
Name of Lobbying Firm to be cancelled ___________________________________________________________________________________
________________________________________________________________________________________
Signature of Lobbyist Date
Return completed form via email to Lobbying@srwmd.org or via mail to:
Contracts and Procurement Coordinator • Suwannee River Water Management District • ATTN: Lobbyist Registration
9225 County Road 49 • Live Oak, FL 32060
I do solemnly swear that all the foregoing facts are true and correct.
___________________________________________________________________
Original Signature of Lobbyist
STATE OF FLORIDA
COUNTY OF ___________________________________
Sworn to (or affirmed) and subscribed before me this ______ day of __________________ 20 ___ , by ______________________________
Personally known ______ OR Produced identification ______ Type of Identification Produced ______________________________________
__________________________________________________________
Notary Signature
(Seal or Stamp)
__________________________________________________________
Print, Type or Stamp Name of Notary
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Change or Cancellation of Lobbyist Registration Suwannee River (Suwannee River Water Management District)

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Completed 4 July 2021

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