Short Form Registration Statement Pursuant to the Foreign Agents Registration Act of 1938, as amended

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OMB NO. 1124-0005; Expires February 28, 2014
U.S. Department of Justice Short Form Registration Statement
Washington, DC 20530 Pursuant to the Foreign Agents Registration Act of
1938, as amended
INSTRUCTIONS. Each partner, officer, director, associate, employee, and
agent of a registrant is required to file a short form registration sta
unless he engages in no activities in furtherance of the interests of th
e registrant’s foreign principal or unless the services he renders to th
e registrant
are in a secretarial, clerical, or in a related or similar capacity. Co
mpliance is accomplished by filing an electronic short form registration
Privacy Act Statement. The filing of this document is required for the
Foreign Agents Registration Act of 1938, as amended, 22 U.S.C. § 611
et seq.,
for the purposes of registration under the Act and public disclosure. P
rovision of the information requested is mandatory, and failure to provi
de the
information is subject to the penalty and enforcement provisions establi
shed in Section 8 of the Act. Every registration statement, short form
registration statement, supplemental statement, exhibit, amendment, copy
of informational materials or other document or information filed with
Attorney General under this Act is a public record open to public examin
ation, inspection and copying during the posted business hours of the
Registration Unit in Washington, DC. Statements are also available onli
ne at the Registration Unit’s webpage: . One copy of
every such document, other than informational materials, is automaticall
y provided to the Secretary of State pursuant to Section 6(b) of the A
ct, and
copies of any and all documents are routinely made available to other ag
encies, departments and Congress pursuant to Section 6(c) of the Act.
Attorney General also transmits a semi-annual report to Congress on the
administration of the Act which lists the names of all agents registered
the Act and the foreign principals they represent. This report is avail
able to the public and online at: .
Public Reporting Burden. Public reporting burden for this collection of
information is estimated to average .429 hours per response, including
time for reviewing instructions, searching existing data sources, gather
ing and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding this burden estimate
or any other aspect of this collection of information, including sugges
for reducing this burden to Chief, Registration Unit, Counterespionage S
ection, National Security Division, U.S. Department of Justice, Washingt
DC 20530; and to the Office of Information and Regulatory Affairs, Offic
e of Management and Budget, Washington, DC 20503.
1. Name 2. Registration No.
3. Residence Address(es) 4. Business Address(es)
5. Year of Birth
NationalityPresent Citizenship 6.
If present citizenship was not acquired by birth,
indicate when, and how acquired.
7. Occupation
8. What is the name and address of the primary registrant?
Name Address
9. Indicate your connection with the primary registrant:
□ partner □ director □ employee □ consultant
□ officer □ associate □ agent □ subcontractor
□ other (specify) _______________________________
10. List every foreign principal to whom you will render services in s
upport of the primary registrant.
11. Describe separately and in detail all services which you will rende
r to the foreign principal(s) listed in Item 10 either directly, or through the primary registrant listed in Item 8, and the date(s) of su
ch services. (If space is insufficient, a full insert page must be
Formerly CRM-156
Revised 03/11

12. Do any of the above described services include political activity a
s defined in Section 1(o) of the Act and in the footnote below? Yes
□ No □
If yes, describe separately and in detail such political activity.
13. The services described in Items 11 and 12 are to be rendered on a

□ full time basis □ part time basis □ special basis
14. What compensation or thing of value have you received to date or wi
ll you receive for the above services?
□ Salary: Amount $ ___________ per ___________ □ Commission at _________ % of _______________
□ Salary: Not based solely on services rendered to the foreign principa
□ Fee: Amount $ ___________ □ Other thing of value _________________________
15. During the period beginning 60 days prior to the date of your obligation
to register to the time of filing this statement, did you
make any contributions of money or other things of value from your own f
unds or possessions and on your own behalf in
connection with any election to political office or in connection with a
ny primary election, convention, or caucus held to select
candidates for any political office? Yes
□ No □
If yes, furnish the following information:
Date Amount or Thing of Value Political Organization or Candidate
Location of Event
In accordance with 28 U.S.C. § 1746, the undersigned swears or affirm
s under penalty of perjury that he/she has read the
information set forth in this registration statement and that he/she is
familiar with the contents thereof and that such contents are in
their entirety true and accurate to the best of his/her knowledge and be
______________________________ _____________________________________
(Date of signature) (Signature)
Footnote: Political activity as defined in Section 1(o) of the Act mea
ns any activity which the person engaging in believes will, or that the
person intends to, in any way influence
any agency or official of the Government of the United States or any sec
tion of the public within the United States with reference to formulatin
g, adopting, or changing the
domestic or foreign policies of the United States or with reference to t
he political or public interests, policies, or relations of a government
of a foreign country or a foreign political