Form 10 THE COMMONWEALTH OF MASSACHUSETTS OFFICE OF THE ATTORNEY GENERAL NON-PROFIT ORGANIZATIONS/PUBLIC CHARITIES DIVISION ONE ASHBURTON PLACE BOSTON, MASSACHUSETTS 02108 Form 10 Registration Statement to be filed by Professional Solicitors, Professional Fund-Raising Counsel, and Commercial Co-Venturers (M.G.L. c. 68, §§ 18-35) Please TYPE or CLEARLY PRINT all entries in black ink. Please complete: Registration for the calendar year ending December 31, 20 . Please note: Registration is done on a calendar-year basis and must be renewed annually. Indicate the type of professional fund-raiser by writing the corresponding code in the box to the right: 1 2 3 1(A) Professional Solicitor Professional Fundraising Counsel Commercial Co-venturer Full legal name under which the registrant conducts business: 1(B) Additional names by which the registrant is known or conducts business: 1(C) Mailing address: Name of principal contact: Title: Address: City: Phone: State: Fax: Zip Code: 1(D) Legal principal place of business: Address: City: State: Zip Code: Form 10 Page 1 of 4 Rev. 09/2010 American LegalNet, Inc. www.FormsWorkFlow.com Form 10 Phone: Email address: Fax: Website (URL): 1(E) If the address in 1(C) is not in-state, give the principal Massachusetts address, if any: Address: City: Phone: 1(F) State: Fax: If the registrant is incorporated, please note below: If you noted "yes," please attach a copy of the Articles of Incorporation to this form. 1(G) Federal ID Number for the registrant, if applicable: Zip Code: Registrant's employee(s) or agent(s) who will be primarily responsible for conducting and supervising campaigns at each office listed above. Attach separate pages if necessary; include ALL sub-contractors.** Name: Title: 1(H) Address: Name: Phone: Title: Address: Phone: **Sub-contractors must be registered and bonded with Massachusetts before solicitation occurs. The registrant holding the contract with the charitable organization is responsible for filing the contract and any applicable financial report with the Division. 2. If the registrant currently has a charitable organization for which it will conduct solicitation or counseling, please place an "X" in the box to the right If you checked this box, please attach a separate page that lists the name and address of the charitable organization and the dates of the current or planned campaign. Massachusetts General Laws Chapter 68, Section 22 states that "Every contract or agreement between a professional fund-raising counsel or a commercial co-venturer or a professional solicitor and a charitable organization required to have a certificate of registration pursuant to [chapter sixty-eight] section nineteen shall be in writing, signed by two officers of the charitable organization, and filed with the director of the division within ten days after such contract or agreement is entered into. No solicitation shall be conducted prior to the filing of such contract or agreement." Professional solicitors must complete the Form 10A for every campaign conducted in Massachusetts. Commercial co-venturers must complete the Form 10B for Massachusetts campaigns. A copy of the contract with the charitable organization should be attached to both the Form 10A and the Form 10B. These forms must be submitted before solicitation can occur. Form 10 Page 2 of 4 Rev. 09/2010 American LegalNet, Inc. www.FormsWorkFlow.com Form 10 3. If the registrant is licensed by, registered with, or has a permit from any governmental agency outside of Massachusetts as a professional solicitor, professional fund-raising counsel, or commercial co-venturer, please complete the following information. (Attach a separate sheet if necessary.) Name of Agency City/State Authorization date (MM/DD/YYYY) 4. If any license or permit has been denied, cancelled, revoked, or suspended, or if any legal or administrative action has been taken against you in connection with solicitation of funds for charitable purposes, please complete the following information. (Attach a separate sheet if necessary.) Action Taken By Type of Action Authorization date (MM/DD/YYYY) 5. If you or any of your employees or agents has ever been convicted of a misdemeanor involving the misappropriation, misapplication, or misuse of money of another, or of any felony, please complete the following information. (Attach a separate sheet if necessary.) Action Taken By Type of Action Authorization date (MM/DD/YYYY) 6. PROFESSIONAL SOLICITORS ONLY: If the registrant has worked for another professional solicitor, he or she must list ALL solicitation-related employment from the last five years on another sheet. Include the name, address, and phone number of the employer, the nature of the employment, and the length of employment. 7. CERTIFICATION BY THE REGISTRANT: Under the pains and penalties of perjury, I certify the above declaration to be true and correct to the best of my knowledge. Signature on behalf of Registrant PRINT name and title Date signed PROFESSIONAL SOLICITORS: Submit this form with the Form 9 surety bond and $1,000 filing fee. PROFESSIONAL FUND-RAISING COUNSEL: Submit this form with a $400 filing fee. COMMERCIAL CO-VENTURERS: Submit this form with the Form 9 surety bond and $200 filing fee. **Fees are payable by check or money order and should be made out to the Commonwealth of Massachusetts.** OFFICE USE ONLY Form 10 Payment received: Page 3 of 4 Rev. 09/2010 American LegalNet, Inc. www.FormsWorkFlow.com Form 10 Form 10 Page 4 of 4 Rev. 09/2010 American LegalNet, Inc. www.FormsWorkFlow.com