Form 604 Lobbyist Certification Statement

Government Code Section 86103

Form 604 Instructions

Part 1 of 4: Lobby Information




















Part 2 of 4: Lobbyist Ethics Orientation Course

Check one box



If you have not attended the course, when will you attend (Check one)



Part 3 of 4: Agencies Lobbied

Check one box





Will you lobby the State Legislature?



Part 4 of 4: Verification

By signing the verification below, I certify that I have read and understand that I am subject to the prohibitions contained in Government Code Sections 86203 and 86205.

I have used all reasonable diligence in preparing this Statement. I have reviewed this Statement and to the best of my knowledge the information contained herein is true and complete. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.


Signature of Lobbyist Required. Sign document after printing.

Please press 'Create PDF Document' button below. Filled out Form 604 PDF document will be opened. Please print the document and sign at the bottom of the page.


End of the Page, Form 604.