GOVERNMENTAL AFFAIRS AGENTFORM REGREGISTRATIONFOR 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 NameBusiness NameBusiness AddressCityStateZip Code*(Area Code) Telephone NumberAction(s)(Part I)The following questions pertain to the Governmental Affairs Agent (GAA) named above:1. State your occupation:2. Describe your proposed services as a GAA:3. Are you: (please check)4. Calendar period for which compensation as a GAA will be received:New Jersey Election Law Enforcement CommissionPage 1 of 2Form 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.

(Part II)1.If you are employed as a GAA for a Business that has existing Represented Entities, indicate the Represented Entities for which you will perform services.a.b. filed electronically for each new Represented Entity.] Indicate "n/a" if not applicable.I acknowledge that in order to complete my registration and receive a badge as a registered Governmental Affairs Agent that I must appear at the office of the Commission and present valid government issued identification, 2 color photographs and the required annual fee or Form ST-5.Registration Number:PIN:Signature of Governmental Affairs AgentDateNew Jersey Election Law Enforcement CommissionPage 2 of 2Form NR Revised Jan, 2016
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