Professional Licensing Boards and Securities Division 237 Coliseum Drive Macon, Georgia 31217-3858 (478) 207-2440 http://www.sos.state.ga.us/securities/ Brian P. Kemp Secretary of State Georgia Charitable Solicitations Act Paid Solicitor Registration Tanja Battle Executive Director EXECUTION PAGE Statutory Fees (Nonrefundable) Make Check Payable to Georgia Secretary of State INITIAL APPLICATION $250.00 REINSTATEMENT Registration #: ___________________ $250.00 AMENDMENT $15.00 RENEWAL $100.00 WARNING: The registration of a paid solicitor expires on December 31 of each year. Failure to keep this form current and file accurate supplemental information on a timely basis, or failure to keep accurate books and records or otherwise comply with provisions of the Georgia Charitable Solicitations Act of 1988, will constitute a violation of said Act and may result in disciplinary, administrative, injunctive or criminal action. INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT MAY CONSTITUTE CRIMINAL VIOLATIONS. 1. Official Name and Mailing Address of Applicant (Paid Solicitor): 2. Contact Person: 3. Location of Books and Records: Telephone: EXECUTION: On behalf of the applicant identified above, for the purpose of complying with the Charitable Solicitations Act of 1988 (O. C. G. A. 4317-1 et seq.) ("Act"), I hereby certify that the applicant is in compliance with said Act and irrevocably appoints the Secretary of State of the State of Georgia the agent for the applicant upon whom may be served any notice, process or pleading in any action or proceeding against the applicant arising out of, or founded upon, a violation or an alleged violation of said Act. The applicant hereby consents that any such action or proceeding against said applicant may be commenced in any court of competent jurisdiction and proper venue within the State of Georgia by service of process upon Secretary of State with the same effect as if the applicant was a resident of the State of Georgia and had been personally served with process. The undersigned hereby verifies that he had executed this form on behalf of, and with the authority of, said applicant. The undersigned and applicant represent that the information and statements contained herein, including the exhibits attached hereto, and other information filed herewith, are made a part hereof, are current, true and complete. The undersigned and applicant further represent that to the extent any information previously submitted is not amended, such information is currently accurate and complete. Name of authorized Executive Officer (please type or print): Date: Signature of Executive Officer: Official Witness (Notary) Title: THIS PAGE MUST ALWAYS BE COMPLETED IN FULL with original manual signature and notarization with seal. If filing an initial registration or reinstatement of registration, submit entire application. To amend, circle number(s) being amended. Registration does not become effective until all information on this application is received and approved. All paid solicitor registrations expire on December 31. Form S100 Rev. Jan 2010 Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com APPLICANT'S NAME: To amend, circle numbers being amended and file with a completed execution page (S100 page 1) 4. Status of registration in other jurisdictions Enter "1" for pending registrations, "2" if already registered, and leave blank if not registered. AL DE KS MO NM RI WA AK FL KY MS NV SC WI AR GA LA MT NY SD WV AZ HI MA NC OH TN WY CA IA MD ND OK TX CO ID ME NE OR UT CT IL MI NH PA VA DC IN MN NJ PR VT ORGANIZATION 5. Fiscal Year Ends on (Month/Day): 6. Applicant is a: Date of Formation: Corporation Place of Filing: Proprie torship Other: Partnership Limited Liability Company 7. If FOREIGN Corporation, date qualified to transact business in Georgia: 8. Will applicant have physical possession or legal control over any contributions collected in or from the state of Georgia? YES NO If yes, applicant must attach the following to this application: (a) Fiscal year end financial statement for period ending one year prior to date of filing, or for the preceding fiscal year if fiscal year has ended within 90 days of this filing OCGA 43-17-3(c)(3). ). Such financial statement must be prepared in accordance with generally accepted accounting principles. (b) Surety bond satisfactory to the Secretary of State in the sum of $10,000 payable to the State of Georgia OCGA 43-17-4(a). 9. BRIEF DESCRIPTION OF BUSINESS. Provide a brief description of the general character of the business to be conducted or proposed to be conducted by the applicant: CHAPTERS, BRANCHES, AND AFFILIATES List the name and address of each affiliated branch or chapter located in the State of Georgia and the directors of each such branch or chapter. Attach additional sheets as needed. Address Telephone Designated Supervisor Address Telephone Designated Supervisor Address Telephone Designated Supervisor Address Telephone Designated Supervisor Form S100 Rev. Jan 2010 Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com BACKGROUND INFORMATION NOTE: (1) For the purpose of the following questions the term "executive officer" means the chief executive officer, the president, the principal financial officer, the principal operation officer, the treasurer or any other person performing similar functions. (2) All YES answers to questions must be fully explained on page 4 of the application (attach additional sheets as needed) YES 10. In the past ten years has the applicant, executive officer, or control person 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? (b) Arises out of the conduct of solicitation of contributions for a charitable organization? (c) Involves the larceny, theft, robbery, extortion, forgery, counterfeiting, fraudulent concealment, embezzlement, fraudulent conversion, or misappropriation of funds? (d) Involves murder or rape? (e) Involves assault or battery if such person proposes to be engaged in counseling, advising, housing, or sheltering individuals? Or (f) Pled guilty or nolo contendere (no contest) to any other felony offense? 11. Has any court: (a) in the past ten years enjoined the applicant or a executive officer in conne