State of Rhode Island and Providence Plantations DEPARTMENT OF BUSINESS REGULATION SECURITIES DIVISION CHARITABLE ORGANIZATION SECTION 1511 Pontiac Avenue, Bldg. 69-1 Cranston, Rhode Island 02920 FILINGS MUST BE SUBMITTED ON C D - R O M . W E N O L O N G E R A C C E P T P A P E R F IL IN G S E - L IC E N S IN G N O W A V A ILA B L E . A P P LY O N L IN E A T https://elicensing.ri.gov **You can check the status of your application by logging into https://elicensing.ri.gov with your Personal User ID and Password. If you do not have your Personal User ID and Password, please contact the Division at 401-462-9527. APPLICATION FOR PROFESSIONAL FUNDRAISER ANNUAL EXPIRATION: JUNE 30TH ANNUAL FEE: $240.00 CHECKS PAYABLE TO: GENERAL TREASURER STATE OF RI ____ INITIAL APPLICATION _____RENEWAL APPLICATION E-MAIL ADDRESS_________________________________________ FILE NUMBER (if renewal)__________________________________ 1. Name of Organization: _________________________________________________________________________ 2. DBA:_______________________________________________________________________________________ 3. Address:_____________________________________________________________________________________ ____________________________________________________________________________________________ 4. Date/Place of Organization: ___________________________________________________________________ 5. Form of Organization: ______________________________________________________________________ 6. Contact Person and Mailing Address: ____________________________________________________________ ___________________________________________________________________________________________ Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 7. Has any government agency or court enjoined the applicant, its directors, members, trustees, senior level executives, employees or sub-contractors from soliciting contributions? Yes ____ No ____ If yes, please describe:_____________________________________________________________________________________ ____________________________________________________________________________________________ 8. Has applicant's licens e or registration been suspended or canceled by any governmental agency. Yes ____ No ___ If yes, please describe:__________________________________________________________ ____________________________________________________________________________________________ 9. Has any director, officer, member, trustee, partner, senior level executive, employee, or subcontractor of the professional fundraiser been convicted of a felony, pled nolo contendere to a felony charge, or been held liable in a civil action involving fraud, embezzlement, fraudulent conversion or misappropriation of property? Yes _____ No _____ If yes, please provide details: _________________________________________________________ ____________________________________________________________________________________________ Attach the Following: 1. Copies of all contracts with charitable organizations. (must be submitted within ten (10) days after signing, pursuant to R.I.G.L. 5-53.1-9) 2. Bond, if required by R.I.G.L. 5-53.1-8__________________________________ (If bond is not required pursuant to R.I.G.L. 5-53.1-8, indicate this on the line above.) 3. Names and addresses of all officers, agents & employees. 4. Taxpayer status affidavit (attached to application as exhibit 1) I CERTIFY UNDER PENALTY OF PERJURY THAT I HAVE READ THIS APPLICATION AND KNOW THAT ALL STATEMENTS THEREIN ARE TRUE. (Signature) (Date) (Print Name, title and Phone Number) PROFESSIONAL FUNDRAISER FORM) (REV. 01/2013) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com State of Rhode Island and Providence Plantations DEPARTMENT OF BUSINESS REGULATION SECURITIES DIVISION CHARITABLE ORGANIZATION SECTION 1511 Pontiac Avenue, Bldg. 69-1 Cranston, Rhode Island 02920 EXHIBIT 1 MANDATORY ADDENDUM TO LICENSE APPLICATION Tax Payer Status Affidavit / Identity Verification All persons applying or renewing any license, registration, permit or other authority (herein after called "licensee") to conduct a business or occupation in the state of Rhode Island are required to file all applicable tax returns and pay all taxes owed to the state prior to receiving a license as mandated by state law (RIGL §5-76-2) except as noted below. In order to verify that the state is not owed taxes, licensees are required to provide their Social Security Number or Federal Tax Identification Number (for businesses) as appropriate. These numbers will be transmitted to the Division of Taxation to verify tax status prior to the issuance of a license. PLEASE CHECK ONE BOX ONLY, EVEN IF YOU HAVE NEVER BEEN EMPLOYED IN RHODE ISLAND. Licensee Declaration I hereby declare, under penalty of perjury, that I have filed all required state tax returns and have paid all taxes owed. I have entered a written installment agreement to pay delinquent taxes that is satisfactory to the Tax Administrator. I am currently pursuing administrative review of taxes owed to the state. I am in federal bankruptcy. (Case # ) I am in state receivership. (Case # ) I have been discharged from Bankruptcy. (Case # ) Type of Professional/Business License for which you are applying Full Name (Please Print or Type) Social Security Number (or FEIN for Business) Signature Phone Number (including area code if not 401) Date Name of Business (If Applicable) NOTE: This form must be completed, signed and attached electronically to your application in order for us to begin processing. Please call the Department with any questions. Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com