FORM NR
GOVERNMENTAL AFFAIRS AGENT
FOR STATE USE ONLY
NOTICE OF REPRESENTATION
(For Registering a Represented Entity)
NEW JERSEY ELECTION LAW ENFORCEMENT COMMISSION
P.O. Box 185, Trenton, NJ 08625-0185
Phone: (609) 292-8700
Website: www.elec.nj.gov
Name of Governmental Affairs Agent
First Name
Last Name
Badge Number
Business Name
Business Address
City
State
Zip 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 Entity
Address
City
State
Zip Code
Occupation or Principal Business
New Jersey Election Law Enforcement Commission
Page 1 of 3
Form NR Revised Mar, 2023
*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.
Confirmation
Required; First Name
Required; Last Name
Badge Number
Required; Business Name
Required; Business Address
Required; City
Format : Zipcode
Format : Phone
Required;
Required;
Required;
Format : Zipcode
Amendment Specify
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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:
Name
Address
City
State
Zip Code
Occupation
3.
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.
Name
Address
City
State
Zip Code
Occupation or Principal Business
(Part II)
Check one of the following
New Jersey Election Law Enforcement Commission
Page 2 of 3
Form NR Revised Mar, 2023
Format : Zipcode
Format : Zipcode
Required;
The Represented Entity will be represented by the GAA filing this NR.
The Represented Entity will be represented by all GAAs registered under the Business Name indicated herein.
The Represented Entity will be represented by specific GAAs registered under the Business Name indicated herein. They are listed below.
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
(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 Agent
Date
New Jersey Election Law Enforcement Commission
Page 3 of 3
Form NR Revised Mar, 2023
Required;
Required;
Required; Format : Date - mm/dd/yyyy
Required Field
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