SOUTH CAROLINA SECRETARY OF STATE PUBLIC CHARITIES DIVISION REGISTRATION APPLICATION COMMERCIAL CO-VENTURER Filing Instructions All lists, attachments and documents requested in this application must accompany the application or it will be returned for correction--they are not optional. This application must be signed by the CEO/President and CFO/Treasurer. If the persons signing this form are not listed as currently holding those positions, this form will be returned for correction. Include the $50.00 filing fee, payable to South Carolina Secretary of State, with this application. Please contact our office with any questions regarding this form at 803-734-1790 or charities@sos.sc.gov. Mail to: South Carolina Secretary of State, Public Charities Division, 1205 Pendleton St., Suite 525, Columbia, SC 29201. Fundraiser ID: ______________ (Renewal only) Legal name of company: __________________________________________________________________ A. DBA (if applicable): __________________________________________________________________ B. EIN: _____--______________ C. Principal address: _____________________________________________________________________ D. Mailing address (if different): ___________________________________________________________ E. Phone Number: ______________________________ F. E-mail: _____________________________________ Check one: [ ] Initial Registration [ ] Renewal 1. G. Website: ____________________________________ 2. Please provide a contact person for the company: _______________________________________________________________________________________ Name Title _______________________________________________________________________________________ Address, City, State, Zip Code _______________________________________________________________________________________ Daytime Phone Email 3. Company is operating as: [ ] Sole Proprietor [ ] Corporation [ ] Partnership [ ] LLC [ ] Other: ____________ Organized in the State of: _________________________ Date organized: __________________________ 4. Registered agent: ____________________________________________________ Name ______________________________________________________________________________________ Street Address (PO Box cannot be accepted) City State Zip Code ** Companies who have a principal place of business outside the state of South Carolina, and who do not have a registered agent in South Carolina, may elect to use the Secretary of State for its registered agent. Registration Application, Commercial Co-venturer, Revised September 2015 American LegalNet, Inc. www.FormsWorkFlow.com 5. 6. Please provide a list of all current officers and directors of the company, along with their addresses. Is the company currently registered in any other state as a commercial co-venturer? ____No ____ Yes If yes, provide a list of all states where registered. Please provide a list of all charitable organizations with which the company has an active contract in South Carolina. Please attach a list of all charitable organizations with which the company has contracted in South Carolina for the previous three years. Has the applicant, or its directors, principal officers, individual owners, or partners been the subject of a legal or administrative action, including an injunction, concerning a charitable solicitation, fundraising campaign, or campaign with a commercial co-venturer by another local, state, or federal governmental authority including, but not limited to registration or license revocation or denial, fines, injunctions, suspensions, or voluntary agreement to discontinue any charitable solicitation activity? ____No ____ Yes If yes, provide a full description. 7. 8. 9. 10. Has the applicant, or its directors, principal officers, individual owners, or partners been the subject of a criminal conviction, including guilty or nolo contendere pleas, involving any charitable solicitations act, fraud, dishonesty, false statement, forgery, or theft, including identity theft, in a jurisdiction within the United States? ____No ____ Yes If yes, provide a full description and the date of any such conviction. 11. Are any of the officers, directors, trustees, or board members of the commerical co-venturer applicant related to each other? ____No ____ Yes If yes, provide a full description. 12. Are any of the officers, directors, trustees, or board members of the commercial co-venturer applicant related to any director, agent, or employee of a charitable organization under contract with the commercial co-venturer? ____No ____ Yes If yes, provide a full description. I certify that the information furnished in this application and all attached supplementary information is true and correct to the best of my knowledge, information and belief. I understand that the giving of false or incorrect information may constitute a misdemeanor carrying a penalty upon conviction of a fine of not more than two thousand dollars ($2,000.00) or imprisonment for not more than one year, or both, for a first offense. A second or subsequent offense may constitute a felony carrying a penalty upon conviction of a fine of not more than five thousand dollars ($5,000.00) or imprisonment of not more than five years, or both. CHIEF FINANCIAL OFFICER / TREASURER _________________________________________ Print Name _________________________________________ Signature Date _________________________________________ Mailing Address _________________________________________ City, State, Zip _________________________________________ Phone Number CHIEF EXECUTIVE OFFICER / PRESIDENT _________________________________________ Print Name _________________________________________ Signature Date _________________________________________ Mailing Address _________________________________________ City, State, Zip _________________________________________ Phone Number Registration Application, Commercial Co-venturer, Revised September 2015 American LegalNet, Inc. www.FormsWorkFlow.com