North Carolina Department of the Secretary of State Charitable Solicitation Licensing Division P.O. Box 29622 Raleigh, NC 27626-0622 Telephone: 919 - 814 - 5400 Solicitor License Application Form Issue Date: 10/22/2003 Revised 2/16/2018 Page 1 of 2 1. Application Type: Initial Renewal 2. Applicant222s Full Business Legal Name: 3. Applicant222s Principal Telephone Number: 4. Applicant222s Principal Street Address: City: State: Zip Code: 5. Applicant222s Mailing Address: City: State: Zip Code: 6. Applicant222s Internet Site Address: 7. Applicant222s Contact Person Email Address: 8 . Legal Form of Applicant222s Business: Sole Proprietor / Individual Corporation General Partnership Limited Liability Corporation Limited Liability Partnership Other 9 . Applicant222s State of Establishment: 10 . Applicant222s Date of Establishment: 1 1 . For non - NC corporations: P rovide either of the following to verify the applicant222s current legal existence: 1. Certificate of Existence or Certificate of Good Standing from state of incorporation dated no more than six months prior to date of signing of application, or 2. Actual webpage screenshot found on a publicly accessible regulatory authority website dated no more than thirty (30) days prior to the date the license application was signed that includes the following elements: Exact name of the entity as it appears on the license application; and Language clearly verifying its status as a corporation in good standing in the state of incorporation (i.e. 223current224 or 223active224); and Date the information was printed on the face of the document. For un-incorporated applicants: Provide a copy of your assumed name certificate filed with the register of deeds office, showing the register of deeds 222 stamp. 12. If applicant222s principal place of business is located outside North Carolina, ATTACH list of street addresses of any applicant offices located in North Carolina. ATTACHMENT 12 included? Yes No NC Offices 13. Are ANY of applicant222s222 owners, directors, officers, or employees RELATED as parent, spouse, child, or sibling to ANY of applicant222s other directors, officers, owners, or employees? Yes No If answer is YES, attach a brief written explanation. ATTACHMENT 13 included? Yes 14. Are ANY of applicant222s222 owners, directors, officers, or employees RELATED as parent, spouse, child, or sibling to ANY officer, director, trustee, or employee of any charitable organization or sponsor under contract with applicant? Yes No If answer is YES, attach a brief written explanation ATTACHMENT 14 included? Yes 15. Are ANY of applicant222s222 owners, directors, officers, or employees RELATED as parent, spouse, child, or sibling to ANY supplier or vendor providing goods or services to any charitable organization or sponsor under contract with the applicant? Yes No If answer is YES, attach a brief written explanation. ATTACHMENT 1 5 included? Yes 16. Within the last five (5) years, has the applicant, or any of the applicant222s directors, officers, employees, agents, or persons with a controlling interest in the applicant: been convicted of ANY felony? Yes No If answer is YES, attach a brief written explanation. ATTACHMENT 1 6 included? Yes 17. Within the last five (5) years, has the applicant, or any of the applicant222s directors, officers, employees, agents, or persons with a controlling interest in the applicant been convicted of ANY misdemeanor arising from the conduct of a solicitation for ANY charitable organization or sponsor OR charitable or sponsor purpose? Yes No If answer is YES, attach a brief written explanation. ATTACHMENT 17 included? Yes 18. Within the last five (5) years, has the applicant, or any of the applicant222s directors, officers, employees, agents, or persons with a controlling interest in the applicant been enjoined from violating ANY charitable solicitation law in this or ANY other state? Yes No If answer is YES, attach a brief written explanation. ATTACHMENT 18 included? Yes 19. ATTACH a list of the NAMES and PHYSICAL RESIDENCE ADDRESSES of ALL of applicant222s officers, directors, and owners. This section must be completed for sole proprietorships, partnerships, and corporations of all types. American LegalNet, Inc. www.FormsWorkFlow.com North Carolina Department of the Secretary of State Charitable Solicitation Licensing Division P.O. Box 29622 Raleigh, NC 27626-0622 Telephone: 919 - 814 - 5400 Solicitor License Application Form Issue Date: 10/22/2003 Revised 2/16/2018 Page 2 of 2 ATTACHMENT 19 included? Yes 20. ATTACH a list of the NAMES of ALL persons in charge of ANY solicitation activity. ATTACHMENT 20 included? Yes 21. ATTACH the required fee of two hundred dollars ($200.00) (make check payable to: NC Department of the Secretary of State). ATTACHMENT 21 (FEE) included? Yes 22. If Partnership or Corporation, does applicant intend to cover multiple individuals with single license? Yes No If YES, ATTACH list containing names and street addresses for ALL partners, members, officers, directors, employees, and agents of the applicant, as well as all other individuals contracted to work under applicant222s direction. ATTACHMENT 22 included?: Yes 2 3 . ATTACH appropriate BOND or other surety required by N.C.G.S. 131 F - 16(d) in the appropriate amount as follows: ATTACHMENT 23 (BOND) included? Yes Contributions received in last fiscal year Required Bond Amount Up to $100,000 $20,000 Up to $200,000 $30,000 $200,000 and over $50,000 24. Applicant222s signature: I do hereby swear or affirm that the information furnished in this application and all supplemental forms, reports, documents, and attachments are true and correct to the best of my knowledge under penalty of perjury. Signature: Signer222s Name (Print): Signer222s Title (Print): 25. Notarization: The following is for a notary public to place you under oath and then notarize YOUR signature: (County)(State) County and State in which oath or affirmation taken Notary Stamp or Seal goes Here Sworn to and subscribed before me this the (e.g., 1st): Day of (e.g., May): In the year of (e.g., 20 1 3): Notary Public222s Signature: Notary Public222s Name (Print): Date Notary Public222s Commission Expires: OPTIONAL APPLICANT/THIRD PARTY CONTACT INFORMATION Contact Person Name: Contact Person Title: Contact Business/Firm Name: Contact Person222s Electronic Mail Address: Contact Person222s Telephone Number: Contact Person222s Facsimil e Number: DOWNLOAD FORM ONLINE AT: https://www.sosnc.gov/forms/bytitle/CharitiesFundraisingConsultantsSolicitors American LegalNet, Inc. www.FormsWorkFlow.com