(Rev - Kentucky



(EBEC-EAL-201 Rev. 5/2020) INITIAL REGISTRATION STATEMENTExecutive Agency Lobbyist/Employer/Real Party in InterestAfter completing, submit your Initial Registration Statement by mail, fax, or email to the location below:Commonwealth of KentuckyExecutive Branch Ethics Commission1025 Capital Center Drive, Suite 104Frankfort, Kentucky 40601PHONE (502) 564-7954 FAX (502) 696-5091, EMAIL: ethicsfiler@-361741112659Do Not Submit Registration Fees with the Initial Registration StatementRegistration fees are paid on an annual basis by the Employer/Real Party In Interest upon the filing of the annual Updated Registration Statement between July 1 and July 31 following the filing of this Initial Statement.00Do Not Submit Registration Fees with the Initial Registration StatementRegistration fees are paid on an annual basis by the Employer/Real Party In Interest upon the filing of the annual Updated Registration Statement between July 1 and July 31 following the filing of this Initial Statement.This statement must be filed with the Executive Branch Ethics Commission within ten (10) days of engagement. Please read instructions and review Kentucky Revised Statutes 11A.211 prior to filing. Upon termination of this engagement, there is an affirmative duty to notify the Executive Branch Ethics Commission within thirty (30) days. Any person who knowingly files a false statement is in violation of state law and subject to fines and other penalties.A.Executive Agency Lobbyist (EAL) InformationFull Name: FORMTEXT ?????Occupation: FORMTEXT 3. Title: FORMTEXT ?????4.Firm Name: FORMTEXT ?????5.Business Address: FORMTEXT ?????6.Business Telephone: FORMTEXT ????? 7. Cell Phone:: FORMTEXT ?????8. Business Email: FORMTEXT ?????9.Permanent Residential Address: FORMTEXT ?????10.Date of Engagement as Executive Agency Lobbyist with this Employer: FORMTEXT ?????B.Employer Information1.Full name of company/organization: FORMTEXT ?????2.Type of Industry: FORMTEXT ?????3.Business Address: FORMTEXT ?????4.Employer Contact: Name and title of person responsible for completing the Updated Registration Statement/Employer of Executive Agency Lobbyist (each Employer should name one person as a contact).Name: FORMTEXT ?????Title: FORMTEXT ?????Address (if different from Employer above): FORMTEXT ?????Telephone: FORMTEXT ?????E Mail Address: FORMTEXT ?????C.Real Party in Interest Information (if applicable)1.Full name of company/organization: FORMTEXT ?????2.Type of Industry: FORMTEXT ????? 3.Business Address: FORMTEXT ?????4.Name and title of person responsible for completing the Updated Registration Statement/Real Party in Interest (each Real Party should name one person as a contact). Name: FORMTEXT ?????Title: FORMTEXT ?????Address (if different from Real Party above): FORMTEXT ?????Telephone: FORMTEXT ?????E-mail Address: FORMTEXT ?????D.Brief description of the Executive Agency Decision(s) to which EAL's engagement relates: Do Not Leave Blank FORMTEXT ?????E.Listing of Executive Branch Agencies to which engagement relates: Please check all agencies you anticipate contacting in your capacity as an EAL for the employer or real party in interest listed on this form. Constitutional Agencies/Elected Officials FORMCHECKBOX Agricultural Policy, Governor’s Office of FORMCHECKBOX Agriculture, Commissioner of FORMCHECKBOX Attorney General, Office of the FORMCHECKBOX Auditor of Public Accounts FORMCHECKBOX Board of Elections FORMCHECKBOX Coal Marketing and Export, Office of FORMCHECKBOX Governor FORMCHECKBOX Homeland Security, Office of FORMCHECKBOX Kentucky Coal Council FORMCHECKBOX Kentucky Commission on Human Rights FORMCHECKBOX Kentucky Commission on Military Affairs FORMCHECKBOX Kentucky Commission on Women FORMCHECKBOX Kentucky Infrastructure Authority FORMCHECKBOX Lieutenant Governor FORMCHECKBOX Local Government, Department for FORMCHECKBOX Military Affairs, Department for FORMCHECKBOX Minority Empowerment FORMCHECKBOX Registry of Election Finance FORMCHECKBOX Secretary of State FORMCHECKBOX State Budget Director FORMCHECKBOX State Treasurer FORMCHECKBOX Veterans’ Affairs Economic Development Cabinet FORMCHECKBOX ??Bluegrass State Skills Corporation FORMCHECKBOX ??Business Development, Department for FORMCHECKBOX ??Entrepreneurship, Office of FORMCHECKBOX ??Kentucky Economic Development Finance Authority FORMCHECKBOX ??Kentucky Economic Development Partnership FORMCHECKBOX ??Kentucky Innovation Network FORMCHECKBOX ??Secretary, Office of the FORMCHECKBOX ??Small Business Advocacy Commission Education and Workforce Development Cabinet FORMCHECKBOX Americans with Disabilities Act, Ky. Office of FORMCHECKBOX Blind, Office for the FORMCHECKBOX Career and Technical Education, Office of FORMCHECKBOX Center for School Safety FORMCHECKBOX Center for Education & Workforce Statistics FORMCHECKBOX Council on Postsecondary Education FORMCHECKBOX Deaf and Hard of Hearing, Commission on FORMCHECKBOX Early Childhood Advisory Council FORMCHECKBOX Education Professional Standards Board FORMCHECKBOX Education, Department of FORMCHECKBOX Education, Kentucky Board of FORMCHECKBOX Educational Programs/Work Ready Communities FORMCHECKBOX Employment and Training, Office of FORMCHECKBOX Environmental Education Council, Kentucky FORMCHECKBOX Governor’s Scholars Program FORMCHECKBOX Kentucky Education Television FORMCHECKBOX Libraries and Archives, Department FORMCHECKBOX Proprietary Education, Commission on FORMCHECKBOX Secretary, Office of the FORMCHECKBOX Unemployment Insurance Commission FORMCHECKBOX Vocational Rehabilitation, Office of FORMCHECKBOX Workforce Innovation Board, Kentucky FORMCHECKBOX Workforce Investment, Department ofEnergy and Environment Cabinet FORMCHECKBOX Abandoned Mine Lands, Division of FORMCHECKBOX Administrative Hearings, Office of FORMCHECKBOX Air Quality, Division for FORMCHECKBOX Conservation, Division of FORMCHECKBOX Energy Development and Independence, FORMCHECKBOX Environmental Protection, Department for FORMCHECKBOX Environmental Quality Commission FORMCHECKBOX Forestry, Division of FORMCHECKBOX Heritage Land Conservation Fund, Kentucky FORMCHECKBOX Inspector General, Office of FORMCHECKBOX Legal Services, Office of FORMCHECKBOX Mine Permits, Division of FORMCHECKBOX Mine Reclamation and Enforcement, Division of FORMCHECKBOX Mine Safety and Licensing, Office of FORMCHECKBOX Mine Safety Review Commission FORMCHECKBOX Natural Resources, Department for FORMCHECKBOX Oil and Gas Conservation, Division of FORMCHECKBOX Public Service Commission FORMCHECKBOX Secretary, Office of the FORMCHECKBOX State Nature Preserves Commission, Kentucky FORMCHECKBOX Waste Management, Division of FORMCHECKBOX Water, Division of Finance and Administration Cabinet FORMCHECKBOX Administrative Services, Office of FORMCHECKBOX Commonwealth Office of Technology FORMCHECKBOX Controller, Office of the FORMCHECKBOX Facilities & Support Services, Department for FORMCHECKBOX Financial Management, Office of FORMCHECKBOX General Counsel, Office of FORMCHECKBOX Kentucky Gas Pipeline Authority FORMCHECKBOX Kentucky Higher Education Assistance Authority FORMCHECKBOX Kentucky Higher Education Student Loan Corporation FORMCHECKBOX Kentucky Housing Corporation FORMCHECKBOX Kentucky Lottery Corporation FORMCHECKBOX Kentucky River Authority FORMCHECKBOX Local Correctional Facilities Construction Authority FORMCHECKBOX Material and Procurement Services, Office of FORMCHECKBOX Property Valuation, Office of FORMCHECKBOX Retirement Systems, Kentucky FORMCHECKBOX Revenue, Department of FORMCHECKBOX School Facilities Construction Commission FORMCHECKBOX Secretary, Office of the FORMCHECKBOX State Investment Commission FORMCHECKBOX State Property and Buildings Commission FORMCHECKBOX Teachers’ Retirement System, Kentucky FORMCHECKBOX Turnpike Authority of Kentucky Health and Family Services Cabinet FORMCHECKBOX Administrative Hearings FORMCHECKBOX Aging & Independent Living, Department for FORMCHECKBOX Behavioral Health, Developmental & Intellectual Disabilities, FORMCHECKBOX Certificate of Need FORMCHECKBOX Child Care/Child Support FORMCHECKBOX Children with Special Health Care Needs, Commission for FORMCHECKBOX Community Based Services, Department for FORMCHECKBOX Community Volunteerism and Service, Kentucky Commission on FORMCHECKBOX Disability Determination Services FORMCHECKBOX Family Resource Centers & Volunteer Services FORMCHECKBOX Family Support, Division of FORMCHECKBOX Health Benefit & Health Information Exchange, Office of FORMCHECKBOX Health Policy, Office of FORMCHECKBOX Income Support, Department for FORMCHECKBOX Inspector General, Office of FORMCHECKBOX Kentucky e-Health Network Board FORMCHECKBOX Medicaid Services, Department for FORMCHECKBOX Ombudsman, Office of FORMCHECKBOX Policy & Budget Office of FORMCHECKBOX Prevention Violence Resources, Division of FORMCHECKBOX Public Health, Department for FORMCHECKBOX Secretary, Office of theJustice and Public Safety Cabinet FORMCHECKBOX Child Fatality & Near Fatality External Review Panel FORMCHECKBOX Corrections, Department of FORMCHECKBOX Criminal Justice Council FORMCHECKBOX Criminal Justice Training, Department of FORMCHECKBOX Drug Control Policy, Office of FORMCHECKBOX Grants Management Branch FORMCHECKBOX Internal Investigations, Office of FORMCHECKBOX Juvenile Justice, Department of FORMCHECKBOX Juvenile Justice Oversight Council FORMCHECKBOX Kentucky State Police, Department of FORMCHECKBOX Legal Services, Office of FORMCHECKBOX Legislative & Intergovernmental Services, Office of FORMCHECKBOX Motor Vehicle Enforcement FORMCHECKBOX Parole Board FORMCHECKBOX Public Advocacy, Department for FORMCHECKBOX Secretary, Office of the FORMCHECKBOX State Medical Examiner, KentuckyLabor Cabinet FORMCHECKBOX Apprenticeship & Training Council FORMCHECKBOX General Counsel FORMCHECKBOX Kentucky Employers Mutual Insurance FORMCHECKBOX Kentucky Occupational Safety & Health Review Commission FORMCHECKBOX Labor-Management Advisory Council FORMCHECKBOX Labor Relations Board, State FORMCHECKBOX Prevailing Wage Review Board FORMCHECKBOX Secretary, Office of the FORMCHECKBOX Workers’ Claims, Department of FORMCHECKBOX Workers’ Compensation Funding Commission FORMCHECKBOX Workplace Standards, Department of Personnel Cabinet FORMCHECKBOX Administrative Services, Office of FORMCHECKBOX Center for Strategic Innovation FORMCHECKBOX Diversity and Equality, Office of FORMCHECKBOX Employee Insurance, Department of FORMCHECKBOX Employee Relations, Office of FORMCHECKBOX Governmental Services Center FORMCHECKBOX Human Resources Administration, Department FORMCHECKBOX Kentucky Public Employees Deferred Compensation Authority FORMCHECKBOX Legal Services, Office of FORMCHECKBOX Secretary, Office of the Public Protection Cabinet FORMCHECKBOX Alcoholic Beverage Control, Department of FORMCHECKBOX Boxing and Wrestling Authority, Kentucky FORMCHECKBOX Charitable Gaming, Department of FORMCHECKBOX Claims, Board of FORMCHECKBOX Crime Victims Compensation Board FORMCHECKBOX Financial Institutions, Department of FORMCHECKBOX Horse Racing Commission, Kentucky FORMCHECKBOX Housing, Buildings & Construction, Department of FORMCHECKBOX Insurance, Department of FORMCHECKBOX Occupations and Professions, Office of FORMCHECKBOX Secretary, Office of the FORMCHECKBOX Tax Appeals, Board of Tourism Arts and Heritage Cabinet FORMCHECKBOX Creative Services, Office of FORMCHECKBOX Fish and Wildlife Resources FORMCHECKBOX Frankfort Convention Center FORMCHECKBOX Governor’s School for the Arts FORMCHECKBOX Kentucky Artisan Center FORMCHECKBOX Kentucky Arts Council FORMCHECKBOX Kentucky Center for the Arts FORMCHECKBOX Kentucky Heritage Council FORMCHECKBOX Kentucky Historical Society FORMCHECKBOX Kentucky Horse Park FORMCHECKBOX Kentucky Humanities Council FORMCHECKBOX Kentucky Sports Authority FORMCHECKBOX Kentucky State Fair Board FORMCHECKBOX Kentucky State Parks FORMCHECKBOX Secretary, Office of the FORMCHECKBOX Travel, Department of Transportation Cabinet FORMCHECKBOX Aviation, Department of FORMCHECKBOX Budget & Fiscal Management, Office of FORMCHECKBOX Highways, Department of FORMCHECKBOX Highway Safety, Office of FORMCHECKBOX Inspector General, Office of FORMCHECKBOX Kentucky Airport Zoning Commission FORMCHECKBOX Project Delivery & Preservation, Office of FORMCHECKBOX Project Development, Office of FORMCHECKBOX Rural and Municipal Aid, Department for FORMCHECKBOX Secretary, Office of the FORMCHECKBOX Transportation Delivery, Office for FORMCHECKBOX Vehicle Regulation, Department of General Government / Boards and Commissions FORMCHECKBOX Accountancy, Board of FORMCHECKBOX Alcohol and Drug Counselors, Board of FORMCHECKBOX Applied Behavior Analysis, Board of FORMCHECKBOX Architects, Board of FORMCHECKBOX Auctioneers, Board of FORMCHECKBOX Barbering, Board of FORMCHECKBOX Chiropractic Examiners, Board of FORMCHECKBOX Dentistry, Board of FORMCHECKBOX Dieticians and Nutritionists, Board of Certification FORMCHECKBOX Embalmers and Funeral Directors, Board of FORMCHECKBOX Emergency Medical Services, Board of FORMCHECKBOX Executive Branch Ethics Commission FORMCHECKBOX Fee-Based Pastoral Counselors, Board of FORMCHECKBOX Hairdressers and Cosmetologists, Board of FORMCHECKBOX Hearing Instruments, Board of Specialists in FORMCHECKBOX Heating, Ventilation and Air Conditioning Contractors, Board of FORMCHECKBOX Home Inspectors, Board of FORMCHECKBOX Interpreters for the Deaf and Hard of Hearing, Board of FORMCHECKBOX Landscape Architects, Board of Examiners & Registration of FORMCHECKBOX Manufactured Home Certification and Licensure,Board of FORMCHECKBOX Marriage and Family Therapists, Board of Certification of FORMCHECKBOX Massage Therapy, Board of Licensure for FORMCHECKBOX Medical Licensure, Board of FORMCHECKBOX Nursing Home Administrators, Board of Licensure for FORMCHECKBOX Nursing, Board of FORMCHECKBOX Occupational Therapy, Board of Licensure for FORMCHECKBOX Ophthalmic Dispensers, Board of FORMCHECKBOX Optometric Examiners, Board of FORMCHECKBOX Personnel Board FORMCHECKBOX Pharmacy, Board of FORMCHECKBOX Physical Therapy, Board of FORMCHECKBOX Podiatry, Board of FORMCHECKBOX Private Investigators, Board of Licensure for FORMCHECKBOX Professional Art Therapists, Board of Certification for FORMCHECKBOX Professional Counselors, Board of FORMCHECKBOX Professional Engineers and Land Surveyors, Board of Licensure for FORMCHECKBOX Professional Geologists, Board of FORMCHECKBOX Prosthetics, Orthotics, and Pedorthics, Board of FORMCHECKBOX Psychology, Board of Examiners of FORMCHECKBOX Real Estate Appraisers, Board of FORMCHECKBOX Real Estate Commission FORMCHECKBOX Respiratory Care, Board of FORMCHECKBOX Social Work, Board of FORMCHECKBOX Speech-Language Pathology and Audiology, Board of FORMCHECKBOX Veterinary Examiners, BoardAgencies Not Listed: FORMTEXT ?????F. COMPENSATION DISCLOSURE: “Compensation” means “any money, thing of value, or economic benefit conferred on, or received by, any person in return for services, rendered , as to be rendered, by himself or another.” KRS 11A.201(1). Compensation shall be listed by the amount paid or received , the intervals on which the payment is paid or received, and shall include any other compensation received or paid for conducting Executive Branch lobbying efforts. Only include payments that have been made to the date of submitting this form.1. List compensation that has been received by the EAL from both the Employer and the Real Party in Interest, if applicable: FORMTEXT ?????2. List compensation that has been received by the Employer from the Real Party in Interest, if applicable: FORMTEXT ?????I certify under penalty of law that the employer and agent have complied with KRS 11A.236 and that the information given in this Initial Registration Statement is complete and accurate. Any person who knowingly files a false statement is in violation of state law and subject to fines and other penaltiesDate: FORMTEXT ?????Signature_______________________________________________________(Executive Agency Lobbyist)Date: FORMTEXT ?????Signature_______________________________________________________ (Employer Contact)Type name and title of Employer Contact: FORMTEXT ?????Do Not Submit Registration Fees with the Initial Registration Statement ................
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