COMMITTEE/SUBCOMMITTEE APPEARANCE RECORD

Please fill out the entire form, then click the "Submit and Print" button. Two copies of the printed form should be submitted to the Committee Administrative Assistant at the meeting. If you are unable to submit and/or print this interactive form, you may contact the Committee for a .pdf copy of the form or fill out a paper copy at the meeting.

Select Meeting to Attend:
Bill Number (If Applicable):: N/A
Meeting Date:
PCB/PCS/Amendment # or Presentation/Workshop Topic:
Committee/Subcommittee:

(If you are a registered lobbyist or have previously spoken – type in your First and last name, then click the "Look Up" button to locate your information. If not, type in all information requested.)

First Name:

Last Name:

Name:

Title:
Address:
Address (cont):
City:
State:
Zip Code:
Phone Number:
Representing:
Registered Lobbyist:: Yes No
State Employee:: Yes No

(If you are testifying regarding an amendment, please indicate if your position as a proponent or an opponent is the same as on the bill as a whole.)

I Wish To Speak:: No
I Have Been Requested To Speak:: No
Bill:: Proponent Opponent Info Only N/A
Amendment:: Proponent Opponent Info Only N/A

H-16e (Revised 7/11/11)