FOR OFFICIAL USE FRC REG# ____________ FY REG ______________ AMT. ________________ CK # ________________ DATE ________________ Charitable Law Section 150 E. Gay St., 23rd Fl. Columbus, OH 43215 Telephone: (614) 466-3181 Facsimile: (614) 466-9788 www.ag.state.oh.us REGISTRATION FORM FOR A FUND-RAISING COUNSEL (Section 1716.07, Ohio Revised Code) This registration form is to be completed by any fund-raising counsel that at any time collects or has custody of contributions from a solicitation conducted in the state of Ohio. The registration shall be for a period of one year or part of one year and shall expire annually on March 31st. Upon application, payment of a registration fee in the amount of $200.00 and filing of the bond is required. The registration may be renewed for additional one-year periods. Any corporation, partnership, association or other entity that intends to act as a fundraising counsel must register and pay a single fee of $200.00 on behalf of all its members, officers, employees and agents. If you are registering on behalf of the officers, employees and agents of the fundraising counsel and all other persons with whom the fund-raising counsel has contracted to work under its direction, then you must list these individuals and furnish an updated list of such persons to the attorney general within five days of the date of any new employment or contractual arrangement. Initial Registration Renewal Registration EIN: _________________________ 1. ____________________________________________________________________________ (Full Legal Name of Fund-raising Counsel) 2. ____________________________________________________________________________ (Name(s) Under Which Business will be Conducted in Ohio, d/b/a’s (doing business as). 2. (a) If a d/b/a name is used, please attach copies of the Secretary of State filing(s) or other record(s) reflecting registration of this d/b/a. 3. ____________________________________________________________________________ (Street Address of Principal Place of Business) _____________________________________________________________________________ (Mailing Address if Different Than Above) ____________________________________________________________________________ (City) (State) (Zip Code) ____________________________________________________________________________ (Telephone Number) (Fax Number) (Web Address) ____________________________________________________________________________ (Name of Primary Contact Person/Title) (Contact Phone Number/Ext) (E-mail Address) American LegalNet, Inc. www.FormsWorkflow.com 4. ____________________________________________________________________________ (Address of Primary Office, Branch or Affiliate Located in Ohio, if the Above Address is not in Ohio) ____________________________________________________________________________ (City) (State) (Zip Code) (Telephone No.) 5. Will the fund-raising counsel perform any oral or written requests or mailings on behalf of the charity requesting or securing the promise, pledge, or grant of money, property, financial assistance, or any other thing of value? Yes No (If yes, registration as a Professional Solicitor must be completed instead.) 6. Will the fund-raising counsel at any time collect or have custody of any contributions? Yes No (If yes, total gross contributions must be deposited into charity bank account not later than two days after receipt of each contribution and financial reports filed in 1716.05(B)(3)) If no, registration is not required.) 7. Indicate the form of the fund-raising counsel: Corporation 8. accordance with O.R.C Section Partnership Association Individual If other than individual, indicate the state in which the fund-raising counsel was legally established and the date: State established: ________________ Date established: ________________ (mm/dd/yy) 9. Provide the names and addresses of all members, officers, employees or agents contracted to work under the fund-raising counsel’s direction. Attach additional pages if necessary. (Names and addresses of new employees must be furnished to the AG office within 5 days of date of employment or contractual arrangement.) Name Address Title/Position ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 10. Do any members, officers, or agents hold positions within any other fund-raising counsel, professional solicitor or charitable organizations registered in Ohio? Yes No If yes, provide the following: Name of Individual Position Held Name of Organization ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 2 American LegalNet, Inc. www.FormsWorkflow.com 11. Is the fund-raising counsel registered with or otherwise authorized by any other governmental authority in this state or another state to solicit contributions? Yes No If yes, provide the following: ____________________________________________________________________________ (Name of Governmental Authority) (Date Authorized (mm/dd/yy)) ____________________________________________________________________________ (Address) (City) (State) (Zip Code) 12. Has the fund-raising counsel had its registration or authority denied, suspended, revoked or enjoined by any court or other governmental authority in this state or another state or have any current actions against it? Yes No If yes, provide the following: ____________________________________________________________________________ (Name of Governmental Authority) (Date of Action (mm/dd/yy)) ____________________________________________________________________________ (Violations Alleged) ____________________________________________________________________________ (Final Outcome) 13. Has the fund-raising counsel paid any fines or entered into any agreement with any governmental entity in this state or any other state limiting or prohibiting its fundraising activities in any way? Yes No If yes, provide the following: ____________________________________________________________________________ (Name of Governmental Authority) (Date of Agreement (mm/dd/yy)) ____________________________________________________________________________ (Full Details of Agreement) ____________________________________________________________________________ 14. Has any member, officer, employee, or agent of the fund-raising counsel been convicted in the last five years of any violation of Ohio Revised Code Chapter 1716, of any charitable solicitation law of any other jurisdiction or of a felony in this or another state? Yes No If yes, provide the following: ____________________________________________________________________________ (First and Last Name of Individual(s)) ____________________________________________________________________________ (State Where Convicted) (Date of Conviction (mm/dd/yy)) ____________________________________________________________________________ (Case Name) (Case Number) (Court) 3 American LegalNet, Inc. www.FormsWorkflow.com ATTACHMENTS (Please initial next to all attachments included) _____ A list of the names and addresses of all the officers, employees and agents of the fund-raising counsel and all other persons with whom the fund-raising counsel has contracted to work under its direction. _____ If a DBA name is used, please submit copies of the Secretary of State filing(s) or other record(s) reflecting registration of this DBA, if not already on file with our office. _____ A bond on the form prescribed by the Ohio Attorney General in the sum of $25,000.00 payable to the State of Ohio and to any person who may have a cause of action against the principal obligor of the bond for any liability arising out of a violation of R.C. Chapter 1716 or rule thereof. Continuation certificates will not be accepted. _____ A check for the registration fee in the amount of $200.00 made payable to the “Treasurer, State of Ohio.” _____ A copy of the campaign financial report will be provided to the charity. This report should be provided to the charity on the anniversary of the commencement date of a campaign lasting more than a year and not later than 90 days after the completion of the campaign. The report should then be provided to the Attorney General’s office within 7 days of providing it to the charity. See Ohio Revised Code Section 1716.05(B)(3). 4 American LegalNet, Inc. www.FormsWorkflow.com AFFIDAVIT STATE OF _________________: ss: COUNTY OF _________________: I, ____________________________________, being first duly sworn, state that I am the (Name) _________________________________________ of _________________________________ (Title or Office) (Name of Fund-raising Counsel) and further state as follows: 1. I am the individual who has completed the foregoing Registration Form for a Fund-raising Counsel; 2. I have read the foregoing Registration Form and know the contents thereof; 3. The same is true to the best of my knowledge and belief; and, 4. This Registration Form is made for the purpose of complying with the provisions of Chapter 1716 of the Ohio Revised Code. ____________________________________ (Signature) Sworn to and subscribed before me this _______day of _________________20_____. ____________________________________ (Notary Public Signature) Seal ____________________________________ (Printed Name) FRC REG (2/08) 5 American LegalNet, Inc. www.FormsWorkflow.com