GOVERNMENTAL AFFAIRS AGENTFORM NTNOTICE OF TERMINATIONFOR STATE USE ONLYNEW 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 Number*(Area Code) Telephone NumberBusiness NameBusiness AddressCityStateZip CodeEntity listed below have ceased.Name of Represented EntityAddressCityZip codeStateOREffective Date of TerminationOREffective Date of TerminationRegistrationNumberPINSignature of Governmental Affairs AgentDateNew Jersey Election Law Enforcement CommissionForm NT 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.
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