Nebraska Legislature - Lobbyist Reporting Application

FORM
A-R

NEBRASKA LEGISLATURE
APPLICATION FOR REGISTRATION AS A LOBBYIST

Dec 30, 2019

(This report is required to be filed on or before December 31 of each calendar year.)
49-1480.01(3)

Clerk of the Legislature
Room 2014, State Capitol
PO Box 94604
Lincoln, NE 68509-4604
Phone: (402) 471-2608

For Calendar Year of:

Amended Registration

Lobbyist Registration Fee:
{49-1480.01}

Compensated

$200.00

(If you are a salaried employee of your principal, you are a compensated lobbyist.)

Not Compensated

$15.00

(File a Form E for quarterly report exemption. You are not exempt from the Form D Activity Report.)

PLEASE FILL IN ALL BLANKS

LOBBYIST {49-1480(1)}

Name

Moles, Jack

Office Address (Street, Box, or Route)

455 S. 11th Street, Suite B

Permanent Residence (Street, Box, or Route)

City

Lincoln

State

Zip

68508

City

State

Zip

Office Phone

(402) 440-4378

Home Phone

Email Address

jmoles@nrcsa.net

PRINCIPAL {49-1480(2)}

Name

Nebraska Rural Community Schools Association

Office Phone

(402) 335-7732

Office Address (Street, Box, or Route)

455 S. 11th Street, Suite B

Official to Whom Lobbyist is Accountable

City

Lincoln

State

Zip

68508

Nature of Business {49-1480(3)}

Education

AMOUNTS GIVEN or to be given to lobbyist as compensation or reimbursement of lobbying: {49-1480(3)}. Please state the basis for your compensation.
250.00 Per Month

IDENTIFICATION of MATTERS on which principal or lobbyist expects to lobby: {49-1480(5)} Any and all matters concerning the interests of the business.

Description of industry, trade, profession, or interests and groups represented by the principal:

Names and addresses of principal's officers:

GIVE NAME and ADDRESS of any OFFICIAL in the Legislative or Executive Branch and of any members of any such official's staff or immediate family who is employed by you or by anyone acting on your behalf: {49-1480(8)}

I certify that all information presented in this form is accurate to the best of my knowledge.

Moles, Jack

Lobbyist Name

Dec 30, 2019

Date