Securities and Charities Division Office of the Georgia Secretary of State 2 Martin Luther King Jr. Drive SE Suite 313 West Tower - Atlanta, GA 30334 (404) 654-6035 http://www.sos.ga.gov Brian P. Kemp Secretary of State Noula Zaharis Division Director Application for Registration as a Solicitor Agent Pursuant to The Georgia Charitable Solicitation Act of 1988, As Amended Initial Registration - $ 50.00 Amendment - $15.00 Reinstatement - $50.00 INSTRUCTIONS: THIS APPLICATION MUST BE COMPLETED AND FILED BEFORE SOLICITING CHARITABLE CONTRIBUTIONS. ALL AGENT REGISTRATIONS EXPIRE ON DECEMBER 31. ANSWER ALL QUESTIONS COMPLETELY, ATTACHING ADDITIONAL PAGES IF MORE SPACE IS NEEDED. CHECKS SHOULD BE MADE PAYABLE TO THE SECRETARY OF STATE. AMENDMENTS TO THIS REGISTRATION SHOULD BE FILED PROMPTLY, USING THIS FORM, TO REFLECT ANY CHANGES IN THE INFORMATION SUBMITTED. 1. (a) Full Name of Applicant: _____________________________________________________________________________________ (b) Home Address: ____________________________________________________________________________________________ (Address) ______________________________________________________________________________________________________________ (City) (State) (Zip) (Telephone No.) 2. Address of Each Place of Business: _____________________________________________________________________________ (Address) ____________________________________________________________________________________________________________ (City) (State) (Zip) (Telephone No.) 3. Identify the name(s) and address(s) of Paid Solicitor or Fundraising Counsel with which Agent will be affiliated. Indicate if affiliation is as an employee or as an independent contractor. Attach additional pages as needed. Employee Independent Contractor ____________________________________________________________________________________________________________ Name of Paid Solicitor/Fundraising Counsel SOS Registration No. ____________________________________________________________________________________________________________ (Address) ____________________________________________________________________________________________________________ (City) (State) (Zip) ____________________________________________________________________________________________________________ Contact Person Telephone No. Email Address 4. 5. If Applicant is an independent contractor, attach a copy of contract(s) indicated on #3. Attach a list of all other states in which Applicant is registered. Form SA-1 Revised Sept 2014 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com 6. In the past ten years has the applicant been convicted of or pled guilty or nolo contendere (no contest) to a felony or misdemeanor which: (A) Involves the solicitation or acceptance of charitable contributions or the making of a false oath, the making of a false report, bribery, perjury, burglary, or conspiracy to commit any of the foregoing offenses? Yes No (B) Arises out of the conduct of solicitation of contributions for a charitable organization? Yes No (C) Involves the larceny, theft, robbery, extortion, forgery, counterfeiting, fraudulent concealment, embezzlement fraudulent conversion, or misappropriation of funds? (D) Involves murder or rape? Yes No Yes No (E) Involves assault or battery if such person proposes to be engaged in counseling, advising, housing, or sheltering of individuals? 7. Yes No (F) Pled guilty or nolo contendere (no contest) to any other felony offense? Yes No Has any registration in any state ever been denied, revoked, suspended, or withdrawn? Yes No 8. Has Applicant ever been subject to any injunction or disciplinary proceeding by any state agency involving any aspect of fund raising or solicitation? Yes No 9. Has Applicant ever been subject to an order, consent order or any other disciplinary or administrative proceeding pursuant to the unfair and deceptive acts and practices law of any state? Yes No If the answer is "yes" to any of the aforementioned questions or if such proceeding is pending in any state, attach all pertinent information with respect to such injunction, disciplinary proceeding, conviction or charges. You must also complete page 3 of this application. If the applicant is seeking to be qualified to contact contributors and potential contributors in person, the applicant, by signing this application, gives the Office of the Secretary of State authorizes to conduct a criminal history background investigation and signed the attached GBI Consent Form on Page 3. 10. Will applicant solicit contributions in person, as distinguished from mail, telephonic or electronic contact? Yes No If the answer is "YES", provide the information below and complete PAGE 3. Social Security Number: __________________________________ Date of Birth: ____________________________________ SOLICITOR AGENT CERTIFICATION The undersigned applicant represents that the information and statements contained in this application, including the attached exhibits, are current, true and complete. The undersigned further represents that to the extent any information previously submitted is not amended, such information is currently accurate and complete. By signing this certification, the applicant certifies that he/she is at least 18 years of age and that willful misstatements or omissions of fact may result in administrative, civil or criminal action. _________________________________________________________________ Print Name of Applicant _________________________________________________________________ Signature of Applicant ____________________________ Date Sworn to and subscribed before me this _________ Day of _________________________, 20_________ Notary Public ____________________________________________My Commission Expires: _______________________________ Form SA-1 Revised Sept 2014 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Georgia Bureau of Investigation Georgia Crime Information Center Consent Form I hereby authorize the Office of Secretary of State ­ Charities Division to receive any Georgia criminal history record information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia. _____________________________________________________________________________ Full Name (print) _____________________________________________________________________________ Address _____ Sex _____ Race __________________ Date of Birth _________________________ Social Sec