Print Form (Rev.10-12) (717) 783-1720 1-800-732-0999 (WITHIN PA) FAX (717) 783-6014 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CHARITABLE ORGANIZATIONS 207 NORTH OFFICE BUILDING HARRISBURG, PA 17120 Web site: www.dos.state.pa.us/charities REGISTRATION STATEMENT FOR PROFESSIONAL SOLICITOR - FORM BCO-155 INITIAL RENEWAL (CHECK ONE ABOVE) CERTIFICATE # ______________ (RENEWAL APPLICANTS ONLY) FEE REMITTED ___________ EMPLOYER IDENTIFICATION NUMBER (EIN): 1. Business name of applicant: FULL BUSINESS NAME Check if name change 2. Contact person: Contact's E-mail: Previous name: Address for the principal place of business: (Required) Mailing address: (If different than principal) City: State: County: Phone number: 800 number: E-mail (If different than Contact's E-mail): Web site: 3. Any other names under which you conduct business: Zip code: City: State: Fax number: Zip code: 4. Form of organization: a. Corporation (State of Incorporation and Date) b. Partnership c. Individual d. Other 5. If principal place of business is located outside Pennsylvania do you have any offices in Pennsylvania? Yes No If "Yes", attach address(s), telephone number(s) and person(s) in charge of each office. 6. Attach a list of the names and residence addresses of all principals of the organization, including officers, directors, and owners. An applicant formed as an individual is required to list his/her self as a principal. 7. Provide the name of all persons who supervise any solicitation activity with respect to the solicitation of contributions from Pennsylvania residents. 5 American LegalNet, Inc. www.FormsWorkFlow.com 8. If you answer "Yes" to any of the following, attach list of related individuals with names and relationship. Are any of the owners, directors, officers or employees of the applicant related by blood, marriage or adoption to: (A) Any other directors, officers, owners or employees of the applicant? Yes No No (B) Any officer, director, trustee or employee of any charitable organization under contract with applicant? Yes (C) Any supplier or vendor providing goods or services directly or indirectly to any charitable organization under contract with the applicant? Yes No 9. Has the organization ever voluntarily entered into any legally enforceable agreement such as an assurance of voluntary compliance or discontinuance with any District Attorney, Office of Attorney General, local or state governmental agency? Yes No If "Yes", attach copy of such agreement. 10. Has a license, permit or registration of applicant ever been denied, suspended or revoked by any governmental agency, or are No If "Yes", state reasons for such denial, suspension or revocation and attach copy of such proceedings pending? Yes such denial, suspension or revocation. 11. Has applicant, any officer or director of the applicant, any person with a controlling interest in the applicant, or any person the applicant employs, engages or procures to solicit for compensation ever been convicted by a court of any state or the United States of any felony, or any misdemeanor involving dishonesty or arising from the conduct of a solicitation for a charitable organization or purpose? Yes No If "Yes", give complete information. 12. Are all contracts with charitable organizations on file with, and approved by, the Bureau as required by Section 162.9 (f) of the Solicitation of Funds for Charitable Purposes Act? Yes No Not Applicable . If "No", attach copies. File only those contracts regarding the solicitation of contributions from Pennsylvania residents. Renewal registrants, shouldn't re-file contracts previously filed and approved by the Bureau. Item 13 need only be completed by initial registrants 13. Date organization first solicited contributions from Pennsylvania residents on behalf of a charitable organization: ____/____/____ (If not applicable, please state such). I certify that the information provided in this registration, including all statements and documentation is true and correct. I understand that the falsification of any statement or documentation is subject to criminal penalties for unsworn falsifications pursuant to 18 Pa. C.S. Sec. 4904. DATE SIGNATURE OF PRINCIPAL OFFICER OF THE PROFESSIONAL SOLICITOR CHECKLIST TYPE OR PRINT NAME AND TITLE OF PRINCIPAL OFFICER Registration Statement signed. Any attachments to the Registration Statement. Bond Form BCO - 160 completed and signed. Any contracts / solicitation notices not previously filed and approved. $250 registration fee plus $25 fee for each Solicitation Notice - Form BCO - 170, if any. 6 American LegalNet, Inc. www.FormsWorkFlow.com