Charitable Law Section FOR OFFICIAL USE PS REG#:______________ FY REG: ______________ AMT.: ________________ CK #: ________________ DATE: ________________ 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 PROFESSIONAL SOLICITOR (Section 1716.07, Ohio Revised Code) This registration form is to be completed by every professional solicitor before engaging in any solicitation in the state of Ohio. The registration shall be for a period of one year or part of one year and shall expire on March 31st of each year. Upon application, payment of the 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 professional solicitor must register and pay a single fee of $200.00 on behalf of all its members, officers, employees, agents and solicitors. If you are registering on behalf of the officers, employees, agents and solicitors of the professional solicitor and all other persons with whom the professional solicitor has contracted to work under its direction, then you must attach to this registration form a list of the names and addresses of 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 Professional Solicitor e.g., Name of Company, Partnership, Sole Proprietorship, etc.) 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) ___________________________________________________________________________________ (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) (Telephone No.) 5. Provide the names and addresses of all officers, members, employees and agents contracted to work under the professional solicitor’s direction including telemarketers. 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 ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 6. 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 Person Position Held Name of Organization ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 7. Has the Professional Solicitor 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 (attach additional pages if necessary): ____________________________________________________________________________ (Name of Governmental Authority) (Date of Action (mm/dd/yy)) ____________________________________________________________________________ (Violations Alleged) ____________________________________________________________________________ (Final Outcome) American LegalNet, Inc. www.FormsWorkflow.com 8. Has any member, officer, employee, or agent of the professional solicitor been convicted in the last five years of any violation of Ohio Revised Code Chapter 1716, or any charitable solicitation law of any other jurisdiction or of a felony in this or another state? Yes No If yes, provide the following (attach additional pages if necessary): ____________________________________________________________________________ (First and Last Name of Individual(s)) ____________________________________________________________________________ (State Where Convicted) (Date of Conviction (mm/dd/yy)) ____________________________________________________________________________ (Case Name) (Case Number) (Court) 9. Has the professional solicitor paid any fines or entered into any agreement with any governmental entity in this state or another state limiting or prohibiting its fundraising activities in any way? Yes No If yes, provide the following (attach additional pages if necessary): ____________________________________________________________________________ (Name of Governmental Authority) (Date of Agreement (mm/dd/yy)) ____________________________________________________________________________ (Full Details of Agreement) ____________________________________________________________________________ 10. Has your organization ever been cited for any Do Not Call violations in any jurisdiction in which this organization solicits? Yes No If yes, provide the following (attach additional pages if necessary): ____________________________________________________________________________ (Jurisdiction) (Date of Violation (mm/dd/yy)) ____________________________________________________________________________ (Violations Alleged) ____________________________________________________________________________ (Status) American LegalNet, Inc. www.FormsWorkflow.com ATTACHMENTS (Please initial next to all attachments included) It is not necessary to submit copies of solicitation notices and contracts that have been previously filed with our office. _____ A list of names and addresses of all members, officers, employees and agents of the professional solicitor and all other persons with whom the professional solicitor has contracted to work under its direction. If no attachment is provided, please be advised that only those persons named in item #5 will be considered registered, provided all other filing requirements are met. Any other/additional solicitors not named, including but not limited to, supervisors, telemarketers, etc. must be separately registered and bonded, have paid a registration fee as well as have filed relevant solicitation notices, consent statements and contracts prior to soliciting in Ohio. _____ 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.” _____ If not already on file with the Attorney General’s office, a completed Solicitation Notice form for each new solicitation campaign conducted on behalf of a charitable organization. If the campaign is continuous, a copy of your solicitation notice is not required at registration renewal. The Solicitation Notice shall include a sworn statement by the charitable organization on whose behalf the professional solicitor is acting certifying that the Solicitation Notice and any accompanying material is true and correct to the best of its knowledge. _____ If not already on file with the Attorney General’s office, a copy of the contract with each charitable organization on whose behalf the professional solicitor is acting. 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 Professional Solicitor) and further state as follows: 1. I am the individual who has completed the foregoing Registration Form for a Professional Solicitor; 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) ____________________________________ (Printed Name) Seal PS REG (2/08) American LegalNet, Inc. www.FormsWorkflow.com