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 CD-ROM. WE NO LONGER ACCEPT PAPER FILINGS E-LICENSING NOW AVAILABLE. APPLY ONLINE AT 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 SOLICITOR ANNUAL EXPIRATION: JUNE 30 TH 1. NAME: ____________________________________________________ 2. DATE OF BIRTH: ___________________________________________ 3. SOCIAL SECURITY NUMBER: _______________________________ 4. ADDRESS: ____________________________________________________________________________________ STREET CITY STATE ZIPCODE 5. NAME, ADDRESS, E-MAIL ADDRESS, AND PHONE NUMBER OF EMPLOYING FUNDRAISER: ____ INITIAL APPLICATION ____ RENEWAL APPLICATION 6. CONTACT SUPERVISOR AND MAILING ADDRESS: 7. HAS ANY LICENSE OR REGISTRATION BEEN DENIED, CANCELLED OR REVOKED, OR HAS ANY ACTION BEEN TAKEN AGAINST YOU IN CONNECTION WITH SOLICITATION OF FUNDS FOR CHARITABLE PURPOSES? ____ YES _____ NO 8. HAVE YOU EVER BEEN CONVICTED OF A CRIME INVOLVING THE MISUSE OR THEFT OF MONEY? ___YES ___ NO 9. HAVE YOU EVER BEEN CONVICTED OF A CRIME OF DISHONESTY, THEFT, BURGLARY, DECEPTION, OR FRAUD? ____YES ____NO 10.SUBMISSION OF TAX PAYER 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) 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. American LegalNet, Inc. www.FormsWorkFlow.com