Print Form The State of South Carolina Office of the Secretary of State Mark Hammond Public Charities Division P. O. Box 11350 Columbia, SC 29211 E-mail charities@scsos.com 8 0 3 -7 3 4 -1 7 9 0 $50.00 Filing Fee Website www.scsos.com Individual Professional Solicitor Registration Statement [ ] Initial Registration ________________ [ ] Renewal Renewals, Enter Fundraiser Regis tration #: __________ This application must be submitted prior to any solicitation on behalf of a charitable organization. 1. (a) Full Name of Professional Solicitor:______________________________________________________ (b) Home Address_______________________________________________________________________ _____________________________________________________________________________________ (Telephone No.) (City) (State) (Zip) 2. Date of Birth: _______________________ 3. Work Address: _________________________________________________________________________ _____________________________________________________________________________________ (City) (State) (Zip) (Telephone No.) 4. Enter all past and present employment as a professional solicitor. List present employment first, and include all terms of remuneration agreed upon with PFRs. Attach additional sheets if space is insufficient for the answer. (a) Name of Employer: _____________________________________________________________ Address and Ph. No. _____________________________________________________________ ______________________________________________________________________________ Terms of Remuneration: __________________________________________________________ ________________________________ ______________________________________________ Period (Mo/Yr): ________________________________________________________________ (b ) Name of Employer: _____________________________________________________________ Address and Ph. No. _____________________________________________________________ ______________________________________________________________________________ Terms of Remuneration: __________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com Period (Mo/Yr): ________________________________________________________________ 5. Are you authorized by any other state or local agency to solicit contributions for charitable or other organizations? [ ] YES [ ] NO **If “YES”, what states and charitable organizations? 6. Has your authority to solicit contributions been denied, cancelled, suspended or revoked ,or has any disciplinary or legal action been taken against you by any governmental authority or is one pending in relation to any fundraising activity? [ ]YES [ ]NO **If "YES", what action was taken? (Attach additional sheets if necessary) 7. Have you ever been the subject of a criminal conviction whether the applicant, or its dirctors, principal officers, individual owners, or partners has been the subject of a criminal convicition, including guilty or nolo contendere pleas, involving any charitable solicitations act, fraud, dishonesty, or false statement in a jurisdiction within the United States? [ ]YES [ ]NO ** if “YES”, give a description of the conviction and date of conviction. (Attach additional sheets if necessary) Please read each of the following items. After reading each item, sign your initials in the space provided at the left of each numbered item. Your application cannot be accepted unless you read and initial each item. ___ 8. The Solicitation of Charitable Funds Act requires that I, as a paid professional solicitor, disclose my status as a professional or paid solicitor upon solicitation of any potential donor. ___ 9. The Solicitation of Charitable Funds Act requires that I, as a paid professional solicitor must disclose the registered true name of the professional fundraising organization for which I work and the registered true name, location, and purpose of any charitable organizations for which I am soliciting. The Solicitation of Charitable Funds Act requires that upon request of the solicited party, that I, as a solicitor also must disclose the percentage of gross receipts with which the professional solicitor is compensated including the amount the professional solicitor must be reimbursed as payment for fundraising costs. I as a professional solicitor also must disclose the guaranteed miunimum percentage of gross receipts to be remitted or retained by the charitable organization excluding the amount which the charitable organization must pay for fundraising costs. ___ 10. The Solicitation of Charitable Funds Act requires that I, as a professional solicitor upon oral or written request by the solicited party, must deliver to the solicited party within fifteen business days of the request: (1) a financial statement of the charitable organization disclosing assets, liabilities, fund balances, revenue and expenses for the preceding fiscal year. The financial statement must be the most recently submitted annual financial report pursuant to Section 33-56-60; and (2) a copy of the professional solicitor’s or charitable organization’s current registration certification from the Secretary of State. ___11. I understand that violation of one or more provisions of the law as set forth above may result in a temporary or permanent injunction against my activities, administrative fines and may subject me to criminal prosecution. ___12. I understand that copies of the Solicitation of Charitable Funds Act are available to me as well as all other members of the public. American LegalNet, Inc. www.FormsWorkflow.com I, the registrant, certify under the penalty of perjury, that I have read and I understand each of the items #8 through #12, and I have initialed each item accordingly. I, the registrant, certify under the penalty of perjury, that the statements made in this document and in any accompanying papers are true to the best of my knowledge and belief. ____________________________________________ _____ Signature of Registrant _______________________________________ __________ Title _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date NOTES 1. This statement and accompanying documentation are a public record, copies of which will be provided upon request to any interested person. 2. Pursuant to §33-56-145 (B), any person who knowingly and willfully violates the provisions of this chapter or who knowingly and willfully gives false or incorrect information to the Secretary of State is guilty of a misdemeanor. 3. Please refer to S.C. Code § 33-56-110 (1976) as amended for complete description of all registration requirements. FILING INSTRUCTIONS 1. Type or print in ink the answer to all applicable items. Enter "NA" for any item which is not applicable. 2. A mandatory fee of $50.00 payable to the Secretary of State must accompany this statement. 3. If there is insufficient space on this form for answers, attach additional sheet(s) with reference to the question number for which you are answering. X:\FORMS\EXTERNAL\Individual Solicitor Registration.DOC Rev. 6/19/2008 9:12:00 AM American LegalNet, Inc. www.FormsWorkflow.com