Lobbyist Disclosure Form

							                                                  Lobbyist Disclosure Form
 Complete the information as indicated below. This form shall be filed with the City of Tampa Ethics Office (Department
 of Human Resources) within three days of the lobbying activity.
 Name:                                                               Business Address:


 Name of Represented Business:                                        Address of Business Represented:


 Name of City official/City Employee contacted:                       Date of contact:


 General and specific area of discussion concerning City business:




 Nature and extent of any direct business association or partnership with any City official/employee:




 Signature:                                                          Date:


                                                     FOR ETHICS OFFICE USE ONLY
 Date Received:
                                                                     Dept. Log Verification:   ____ Yes   ____ No

                                                                     Other:
 Financial Report:   ____ Yes ____ No

(5/04)




                                                  Lobbyist Disclosure Form
 Complete the information as indicated below. This form shall be filed with the City of Tampa Ethics Office (Department
 of Human Resources) within three days of the lobbying activity.
 Name:                                                               Business Address:


 Name of Represented Business:                                        Address of Business Represented:


 Name of City official/City Employee contacted:                       Date of contact:


 General and specific area of discussion concerning City business:




 Nature and extent of any direct business association or partnership with any City official/employee:




 Signature:                                                          Date:


                                                     FOR ETHICS OFFICE USE ONLY
 Date Received:
                                                                     Dept. Log Verification:   ____ Yes   ____ No

                                                                     Other:
 Financial Report:   ____ Yes ____ No

(5/04)