City of Dallas

City of Dallas

LOBBYIST REGISTRATION FORM

REGISTRANT NAME:__A_d_a_p_t _P_h_a_rm__a_,_I_n_c.____________

REGISTRATION

FILING

NUMBER: _2_0_1_9_0_1_1_4_1_7_0_3_1_9_7_2_ DATE: __1_/1_4_/_2_0_1_9_

SECTION I: BASIC GUIDELINES ? Unless exempt under Section 12A-15.4 of the Dallas City Code, a person must register with the City

Secretary if the person has done any of the following during a calendar quarter:

1. Received compensation or reimbursement of $200 or more for lobbying; or 2. Lobbied as the agent or employee of a person who received compensation or reimbursement

of $200 or more for lobbying.

? A separate registration form is required for each client. ? A $300 annual fee must be paid prior to registering. ? Initial registration must be filed no later than five days after beginning lobbying activities or, if a zoning

case is involved, within five days after the zoning application is filed with the city. ? A subsequent registration must be filed annually with the city secretary by January 15 each year.

SECTION II: REGISTRANT INFORMATION

Registrant's Name:

_A_d_a_p_t _P_h_a_rm__a_, _I_n_c._____________________________________________________

Address:

City/St/Zip: Nature of Registrant's Business:

Form of Registrant's Business:

_c/_o__2_8_L_ib_e_r_t_y_S_h_i_p_W__a_y_, _S_u_it_e_2_8_1_5________________________________________

Sausalito, CA 94965

(415) 903-2800

_________________________________________ Telephone:_________________

_P_h_a_rm__a_ce_u_t_ic_a_l_m__a_n_u_fa_c_t_u_ri_n_g____________________________________________

Individual X Corporation Partnership Other

If Other, describe:

____________________________________________________________________

SECTION III: INFORMATION ON FILER IF REGISTRANT IS NOT AN INDIVIDUAL

(MUST BE AUTHORIZED OFFICER OR AGENT OF REGISTRANT)

Name:

_J_e_n_n_ie__U_n_g_e_r_S_k_e_lt_o_n___________________________________________________

Address:

_2_8_L_i_b_e_rt_y_S_h_i_p_W__a_y_, _S_u_it_e_2_8_1_5___________________________________________

City/St/Zip:

_S_a_u_sa_l_it_o_, _C_A__9_4_9_6_5__________________________Telephone:(_4_1_5_) _9_0_3_-_2_8_00______

Position Held: _D_e_s_ig_n_a_t_e_d_A_g_e_n_t_f_o_r_F_il_e_r_______________________________________________

OFFICE OF THE CITY SECRETARY

1 Report ID:4910rev. 05/17/2014 DALLAS, TX 75201

City of Dallas

LOBBYIST REGISTRATION FORM

SECTION IV: INFORMATION ON LOBBYING FIRM FOR WHICH REGISTRANT IS AN AGENT OR EMPLOYEE (IF APPLICABLE)

Firm Name:

_____________________________________________________________________

Address:

_____________________________________________________________________

City/St/Zip:

_____________________________________ Telephone: _________________

Nature of Firm's

Business:

_____________________________________________________________________

SECTION V: NAME OF REGISTRANT'S AGENT(S) OR EMPLOYEE(S) ACTING AS LOBBYIST(S) FOR CLIENT (IF APPLICABLE)

Agent/Employee Name: __E_d___Le_a_h_y_____________________________________________________

Agent/Employee Name: ______________________________________________________________

Agent/Employee Name: ______________________________________________________________

Agent/Employee Name: ______________________________________________________________

Agent/Employee Name: ______________________________________________________________

SECTION VI: REGISTRANT'S PRIOR EMPLOYMENT OR SERVICE WITH THE CITY

Was registrant a city official or employee in the preceding 24 months?

Yes X No

If Yes, Position Held: ________________________________________________________________

By filing this registration, I, as a former city official or employee, swear or affirm that, to the best of my knowledge, my lobbying activities have not violated and will not foreseeably violate Article III, Chapter 12A of the Dallas City Code, which governs former city officials and employees.

Yes X No Not Applicable

Client's Name:

SECTION VII: CLIENT INFORMATION _A_d_a_p_t_P_h_a_r_m_a_,_I_n_c_.___________________________________________________

Address:

_c_/_o_2_8__L_ib_e_r_ty__S_h_ip__W_a_y_,_S_u_i_te__2_8_1_5______________________________________

City/St/Zip:

Nature of Client's Business:

_S_a_u_s_a_li_to_,_C_A__9_4_9_6_5_________________________ Telephone: ___(_4_1_5_)_9_0_3_-_2_8_0_0_ _P_h_a_r_m_a_c_e_u_ti_c_a_l _m_a_n_u_f_a_ct_u_r_in_g___________________________________________

Form of Client's Business:

Individual X Corporation

Partnership

Other

If Other, describe:

___________________________________________________________________

OFFICE OF THE CITY SECRETARY

2 Report ID:4910rev. 05/17/2014 DALLAS, TX 75201

City of Dallas

LOBBYIST REGISTRATION FORM

SECTION VIII: INFORMATION ON CLIENT'S AUTHORIZED OFFICER OR AGENT IF CLIENT IS NOT AN INDIVIDUAL

Name:

__J_e_n_n_ie__U_n_g_e_r_S_k_e_lt_o_n__________________________________________________

Address:

__c/_o__2_8_L_ib_e_r_t_y_S_h_ip__W__a_y,__S_u_it_e_2_8_1_5_______________________________________

City/St/Zip:

__S_au_s_a_l_it_o_, _C_A_9_4_9_6_5____________ Telephone: _(4_1_5_)__9_0_3_-2_8_0_0_______________

Position Held: __D_e_si_g_n_a_te_d__A_g_e_n_t_f_o_r _F_il_e_r ______________________________________________

SECTION IX: INFORMATION ON ANY OTHER PERSON(S): (1) ON WHOSE BEHALF REGISTRANT HAS BEEN ENGAGED; (2) WHO IS CONTRIBUTING TO REGISTRANT'S COMPENSATION; OR (3) WHO PLANS, SUPERVISES, OR CONTROLS REGISTRANT'S LOBBYING EFFORTS ON BEHALF OF CLIENT

Name:

____________________________________________________________________

Address:

____________________________________________________________________

City/St/Zip:

____________________________ Telephone: ___________________________

Nature of Business:

____________________________________________________________________

Name:

____________________________________________________________________

Address:

____________________________________________________________________

City/St/Zip:

Nature of Business:

____________________________ Telephone: ___________________________

____________________________________________________________________ SECTION X: CONTINGENT FEE INFORMATION

Is registrant lobbying for client on a contingent fee basis (whether through employment or

another arrangement)?

Yes X No

SECTION XI: LIST MUNICIPAL QUESTION(S) ADDRESSED ON CLIENT'S BEHALF IN THE THREE MONTHS PRECEDING REGISTRATION

(SEE SCHEDULE A ? LOBBYING ACTIVITY FOR PRECEDING THREE MONTHS)

Was any information required to be reported under this section (on Schedule A ? Lobbying Activity for Preceding Three Months) disclosed in the most recent quarterly activity report?

Yes X No

If yes, that information is not required to be included in this registration.

OFFICE OF THE CITY SECRETARY

3 Report ID:4910rev. 05/17/2014 DALLAS, TX 75201

City of Dallas

LOBBYIST REGISTRATION FORM

SECTION XII: LIST MUNICIPAL QUESTION(S) TO BE ADDRESSED ON CLIENT'S BEHALF IN THE THREE MONTHS FOLLOWING REGISTRATION

(IF FORESEEABLE) (SEE SCHEDULE B ? LOBBYING ACTIVITY FOR FOLLOWING THREE MONTHS)

SECTION XIII: FOR MUNICIPAL QUESTION(S) RELATING TO A ZONING CASE, DESCRIBE ALL CONTACTS MADE REGARDING THE CASE BEFORE REGISTRATION WAS FILED (SEE SCHEDULE C ? LOBBYING

ACTIVITY ON ZONING CASES)

SECTION XIV: STATEMENT OF AFFIRMATION

BY FILING THIS REGISTRATION, I SWEAR OR AFFIRM UNDER PENALTY OF PERJURY THAT, TO THE BEST OF MY KNOWLEDGE, ALL INFORMATION CONTAINED IN THE REGISTRATION IS TRUE AND CORRECT AND THAT THE REGISTRATION IS COMPLETE AND INCLUDES ALL INFORMATION REQUIRED TO BE DISCLOSED UNDER ARTICLE III-A, CHAPTER 12A OF THE DALLAS CITY CODE.

X YES NO

OFFICE OF THE CITY SECRETARY

4 Report ID:4910rev. 05/17/2014 DALLAS, TX 75201

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