GOVERNMENTAL AFFAIRS AGENTFORM REGREGISTRATIONFOR STATE USE ONLYNEW JERSEY ELECTION LAW ENFORCEMENT COMMISSIONP.O. Box 185, Trenton, NJ 08625-0185Phone: (609) 292-8700Website: www.elec.nj.govName 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 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.ConfirmationRequired;Required;Required;Required;Required; Format : Zipcode Format : Phone

New Agent Registration

Amendment, Specify Below

Employed solely as a GAA.

Employed as a GAA in addition to having other duties. If so, please explain other duties:

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 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 Mar, 2023Required;Required;Required; Format : Date - mm/dd/yyyyCheck here if all Represented Entities should be associated to the GAA.Check here to list the existing Represented Entities of the Business that should be associated to the GAA.Check here to list any new Represented Entities. [A separate Notice of Representation (Form NR) must beRequired Field