900 604
EEIGCham Central Office
EEIGCham CALIFORNIAFORM FORM FAIR POLITICAL PRACTICES COMM. PROTOCOL & DIPLOMACY
Lobbyist Certification Statement The “Lobbyist Certification Statement” is used for:
Initial certification of an individual who qualifies as a lobbyist, including an individual contract lobbyist. Renewal of lobbyist certification.
Certification Requirements: Lobbyists are required to complete Form 900 - Lobbyist Certification Statement and provide a recent photograph (head and shoulders only). The Form 900 must be filed with the EEIGCham as an attachment to one of the following: Form 901 - lobbying firm’s registration, or Form 903 - lobbyist employer/coalition registration, or Form 905 - firm’s or employer’s Amendment to Registration.
Renewing a Registration: • Submit a 100 € certification fee (for 3 year). New Registration: • Submit a 100 € certification fee (for 3 year). Lobbyists are required to attend an ethics orientation course conducted by the EEIGCham. The EEIGCham will notify lobbyists of course dates, and will provide a certificate of completion of the course. If the course has not been completed within the previous 12 months: New lobbyists must take the course within 12 months after qualifying as a lobbyist. Lobbyists renewing their certifications must take the course within the previous 12 months.
lobbyist certification statement indicating the date the course was taken. Lobbyists who have filed a conditional certification statement must file an amended Form 900 within 30 days following completion of the course. Indicate the date you completed the course and file to the Central Office. NOTE: Do not attach your original certificate of course completion. Maintain this certificate in your records. A lobbyist may list the agencies he/she lobbies on Form 900. (If more space is needed, include an attachment.) If none are listed, the lobbyist will be registered to lobby all agencies identified on the Lobbyist Employer or Lobbying Firm Registration Statement and all subsequent amendments. Lobbyists are subject to certain restrictions outlined on the reverse of Form 900.
Filing Deadlines: New Lobbyists: Within 30 days of qualifying as a lobbyist. Lobbyists Renewing Certification: Between November 1 and December 31.
Amendment to Certification: Within 30 days of any change to the information contained on the Form 900 (e.g., change of employer or firm) an amended Form 900 must be filed with the Central Office as an attachment to your employer’s or firm’s completed Form 905 (Amendment to Registration).
The lobbyist certification is conditional until the course is taken. Failure to take the course at the times specified will void a conditional certification. Once voided, an individual is prohibited from acting as a lobbyist until he/she has completed the course and filed an amended
EEIGCham Form 900 EEIGCham Advice Email: diplomacy@eeigcham.org www.eeigcham.com
EEIGCham Central Office
For Delegation Use Only
(Date)
Lobbyist Certification Statement Check Box if an Amendment
BUSINESS ADDRESS: (Number and Street)
________________________ Membership N°.
Page _______ of ________
Type or Print in Ink (Last)
900
PROTOCOL & DIPLOMACY
EEIGCham Central Office
NAME OF LOBBYIST:
EEIGCham FORM
For Central Office Use Only
(First)
(M.I.)
(City)
(State)
If this is an Initial Certification, enter the DATE QUALIFIED as a Lobbyist: (Zip Code)
TELEPHONE NUMBER: (
NAME OF LOBBYIST EMPLOYER OR LOBBYING FIRM:
)
FAX NUMBER: (Optional) (
)
MOBIL NUMBR: (Optional)
E-MAIL:
I. LOBBYIST ETHICS ORIENTATION COURSE Check one box: I have not taken the course within the previous 12 months. I will attend the course (check one): New Certification – Within the next 12 months
Renewal – By June 30 of the next calendar year
I completed the course on ______/______/_20____ (Day/Mo/Year) II. AGENCIES LOBBIED Check one box: I will lobby the agencies identified on the Lobbyist Employer or Lobbying Firm Registration Statement (Form 901/903) and subsequent amendments. I will lobby the agencies identified below: Will you lobby the Governmental Agencies? Yes No Agencies: Agency Name : Department : Agency Name :
Department :
Agency Name :
Department :
If more space is needed, check box and attach continuation sheets.
I will lobby the Government Representatives identified below: Lobby the Members of Parliament Yes No Lobby the Public Service Yes No I will lobby the Government Head identified below: Minister Name :
Department :
Minister Name :
Department :
Minister Name :
Department :
If more space is needed, check box and attach continuation sheets.
EEIGCham Form 900 www.eeigcham.com
EEIGCham FORM
EEIGCham Central Office Lobbyist Certification Statement
900
PROTOCOL & DIPLOMACY
EN
Type or Print in Ink Page
III. Sectors of operation: (maximum 5 boxes) Aerospace & Aviation Agriculture & Rural Development Audiovisual , Entertainment & Information Banking & Capital Markets Chemistry & Advanced Materials Clima Action Competition & consumer Affaires Culture Customs & Trade Agreements Defence & Security Economic & Financial Affaires Education Employment & Social Affaires Energy Entrepreneurship & Start-ups’ Environment & Sustainable Development External relations & Institutional Affaires Fisheries & Aquaculture Food Safety Global Health & Medical Tourism
Of
Humanitarian Aid Industry & Technology Transfer Infrastructures’ & Urban Development Insurance & Asset Management Investments & Corporate Finance IT & Telecommunications Justice & Fundamental Rights Mining & Natural Recourses Population & Home Affaires Professional Services Research & Technology Retail, Consumer Goods & Lifestyle Sport Supply Chain, Logistic & Transport Politics Technology & Innovation Tourism Trade & Commodities Youth, Woman & Indigenous Minorities Media and Press
IV. LOBBYIST RESTRICTIONS By signing the verification below, I certify that I have read and understand that I am subject to the prohibitions contained in EEIGCham Lobbying Code of Conduct Manual DECLARATION OF ACCEPTANCE I mentioned above have read the "Internal Regulation Manual" and others officials’ documents of the European Economic Chamber EEIGCham and taken notice of their content. I know that legally valid and the EEIGCham binding contracts can only be signed by the Chairman of the Board of Directors (CEO) of the European Economic Chamber EEIGCham in Brussels. I accept the principles and rules of the European Economic Chamber EEIGCham as laid down in the "Internal Regulation" and I shall be following them. I am also agreed to pay the annual fee of the Delegation to the EEIGCham Central Office, as stipulated by the Board of Directors and other legal and financial impositions as mentioned in the Internal Regulations or others officials’ documents of the European Economic Chamber EEIGCham. I further accept that this declaration is binding and if for any reason I resign or am struck off the membership roll of the EEIGCham Delegation in my country, I shall not be entitled to any refund of membership fees. VERIFICATION By joining the European Economic Chamber EEIGCham, I undertake to respect its ethical positions, including those defined by the bylaw and official documents, also I agree with the Values, Vision and Mission of the EEIGCham. I have used all reasonable diligence in preparing this Application Form. I have reviewed this Form and to the best of my knowledge the information contained herein is true and complete. I certify under penalty of perjury under the International Laws that the foregoing is true and correct, and no investigations by the authorities, against the company or me, business suits, bankruptcy and procedure insolvency. For any dispute I accept the jurisdiction of the ARBITRATION COURTOF INTERNATIONAL JUSTICE (ACIJ) Name: _________________________________________________ Executed On
Title: _________________________________________ By
DATE
SIGNATURE OF RESPONSIBLE
EEIGCham Form 900 www.eeigcham.com
EEIGCham FORM
EEIGCham Central Office
900
PROTOCOL & DIPLOMACY
Lobbyist Certification Statement
EEIGCham Code Section:
Government Code:
No lobbyist or lobbying firm shall:
Each lobbyist, or a lobbying firm, must before undertaking an activity of lobbying with a public body, elected officer, or legislative official, or to an agency official of any agency is required previously inquire about existing procedures and specific codes.
Do anything with the purpose of placing any elected officer, legislative official, agency official, or candidate under personal obligation to the lobbyist, the lobbying firm, or the lobbyist’s or the firm’s employer.
Deceive or attempt to deceive any elected officer, legislative official, agency official, or candidate with regard to any material fact pertinent to any pending or proposed legislative or administrative action.
Additional Information Refer to the EEIGCham Lobbying Code of Conduct Manual for additional information.
Cause or influence the introduction of any bill or amendment thereto for the purpose of thereafter being employed to secure its passage or defeat.
Additional information may be requested from the Central Office.
Attempt to create a fictitious appearance of public favor or disfavor of any proposed legislative or administrative action or to cause any communication to be sent to any elected officer, legislative official, agency official, or candidate in the name of any fictitious person or in the name of any real person, except with the consent of such real person.
Represent falsely, either directly or indirectly, that the lobbyist or the lobbying firm can control the official action of any elected state officer, legislative official, or agency official.
EEIGCham Form 900 EEIGCham Advice Email: diplomacy@eeigcham.org www.eeigcham.com