FORM NRGOVERNMENTAL AFFAIRS AGENTFOR STATE USE ONLYNOTICE OF REPRESENTATION(For Registering a Represented Entity)NEW JERSEY ELECTION LAW ENFORCEMENT COMMISSIONP.O. Box 185, Trenton, NJ 08625-0185(609) 292-8700 or Toll Free Within NJ 1-888-313-ELEC (3532)Website: www.elec.state.nj.usName of Governmental Affairs AgentFirst NameLast NameBadge NumberBusiness NameBusiness AddressCityStateZip Code*(Area Code) Telephone Number(Part I)The following questions pertain to the represented entity from whom the Governmental Affairs Agent (GAA) receives compensation for acting as a GAA.State the full name, business address, and occupation or principal business of the represented entity from whom the GAA receives compensation:1.Name of Represented EntityAddressCityStateZip CodeOccupation or Principal BusinessNew Jersey Election Law Enforcement CommissionPage 1 of 3Form NR Revised Jan, 2016*Leave this field blank if your telephone number is unlisted. Pursuant to N.J.S.A. 47:1A-1.1, an unlisted telephone number is not a public record and must not be provided on this form.
2.If the represented entity named above is a membership organization or corporation whose name or occupation does not clearly reveal the interest in which it seeks advancement through the services of its GAA, please complete the information below:A. Describe the represented entity's primary economic, social, political, or other interest:B. List the person(s) having organizational or financial control of the membership organization or corporation:NameAddressCityStateZip CodeOccupation3.State the full name, business address, and occupation or principal business of any person or entity in whose interest the GAA acts in consideration of the compensation paid, if such person or entity is other than the represented entity listed above in Question #1 of Part I.NameAddressCityStateZip CodeOccupation or Principal Business(Part II)Check one of the followingNew Jersey Election Law Enforcement CommissionPage 2 of 3Form NR Revised Jan, 2016

(Part III)Please list the type(s) of, and any specific, legislation, regulation(s), or governmental process(es), in which the within GAA(s) will be promoting or opposing on behalf of the Represented Entity.Registration Number:PIN:Signature of Governmental Affairs AgentDateNew Jersey Election Law Enforcement CommissionPage 3 of 3Form NR Revised Jan, 2016
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