THE SCHOOL DISTRICT OF PALM BEACH COUNTY
CHIEF OFFICE OF ADMINISTRATION
Lobbyist Notice of Registration
1. Lobbyists fill out the information requested below.
2. Submit completed form to the attention of - Board Clerk, via one of the following:
FAX #: (561) 434-7385
Mail: Palm Beach County School District, 3300 Forest Hill Blvd., Suite C-316, West Palm Beach, FL 33406
3. All registration forms expire on June 30 of the year following the initial registration and must be renewed annually thereafter by July 1.
PBSD 2572 (New 9/19/2016) ORIGINAL - Board Office Clerk
Lobbyist Name
Lobbyist Phone Number
Lobbyist Address
If yes, describe the nature and extent of any business, financial, familial, or professional relationship with any current member of the School
Board, member of a School Board Advisory Committee, Superintendent of Schools, a School District Chief, or employee of the Purchasing
Department:
Client Address
Client Phone Number
Client Name
Interest of Client
Finally, I understand that I shall file a notice of withdrawal to the Palm Beach County School Board within ten (10) days of the
termination of my authority to represent the named client.
Do you have any business, financial, familial or professional relationship, or other relationship with any current member
of the School Board, member of a School Board Advisory Committee, Superintendent of Schools, a School District Chief,
or employee of the Purchasing Department?
Yes No
Lobbyist Email Address
CERTIFICATION
I do solemnly swear or affirm that all the foregoing facts are true and correct and that I have read School Board Policy 2.5905 Lobbyist
Registration and that I am aware of the requirements for periodic filing and submission of other statements.
Signature of Lobbyist
State of Florida, County of
On this the day of , 20
, before me, the undersigned Notary Public of the
State of Florida, personally appeared
(name of indvidual who appeared before notary) whose name(s) is/are subscribed to the within instrument, he/she/they acknowledge that he/
she/they executed it.
Notary Public, State of Florida
My commission expires:
Personally known to me, or
Produced identification
DID take an oath, or DID NOT take an oath
Type of ID produced
