The State of South Carolina Office of the Secretary of State Mark Hammond Public Charities Division Registration Application for a Professional Fundraising Counsel Date: ____________________________ [ ] Initial Registration [ ] Renewal Renewals, ENTER Fundraiser Registration #: _________ GENERAL INSTRUCTIONS The following supplemental information must accompany this application. Answer all questions completely. Your application is a matter of public record and will be furnished to any person upon request. The information that you furnish may be used by prospective contributors. This office receives numerous requests for information from members of the general public who are contemplating making charitable contributions. It is very important, therefore, that you make a full disclosure on all of the questions contained in this application. If you have any questions whatsoever on the application, or whether you should disclose a particular item, contact the Public Charities Division at (803) 734-1790. 1. Enclose a copy of all consulting or fundraising agreements effective in South Carolina. 2. Include a $50.00 filing fee. Make check payable to: "South Carolina Secretary of State.” 3. Notify the Public Charities Division of any changes to this application within 10 days of such changes. 4. Mail to: 5. Please refer to the Solicitation of Charitable Funds Act, S.C. Code § 33-56-110 et seq. for a complete description of registration requirements. Office of the Secretary of State Public Charities Divison P. O. Box 11350 Columbia, SC 29211 (803) 734-1790 American LegalNet, Inc. www.USCourtForms.com 1. Legal Name of Applicant: __________________________________________________ 2. (a) Mailing Address: ______________________________________________________ ________________________________________________________________________ (b) Principal Address: _____________________________________________________ ________________________________________________________________________ (c) Phone Number: ( ____ ) ____________ (d) Fax Number: ( _____ ) _____________ (e) E- mail: _______________________ (f) Web Site ___________________________ (g) List on a sheet of paper the principal addresses and phone numbers of officers and directors of applicant. 3. Please provide a list of employees and their job titles, whether full time, part-time, or contracted. 4. Indicate whether the applicant is: (a) Individual ____, Sole Proprietor ______, Corporation ______, Partnership _____,or other____ organized in the State of ______________________ on ____________________ (Date). (b) Federal ID number:_________________If sole proprietor, SSN number___________ 5. Are you currently registered in any other state as a Professio nal Fundraising Counsel? Yes ____ No ____. If so, list all such states. 6. Do you ever have custody of contributions or any financial records of contributions of the charitable organization with which you are contracted? ___Yes ___ No. 7. Is any principal officer, director, owner or partner of the applicant also an officer, director, shareholder, owner or partner of any non-profit or charitable organization? Yes ___ No ___. If so, provide a full description. 8. Please provide a statement as to whether the applicant, or its directors, principal officers, individual owners, or partners is or has 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 and, if so, a written explanation of those actions. 9. Please provide a statement as to whether the applicant, or its directors, principal officers, American LegalNet, Inc. www.USCourtForms.com individual owners, or partners have been the subject of a criminal conviction, including guilty or nolo contendere pleas involving fraud, dishonesty, false statement or any violation of any charitable solicitations act in any jurisdiction within the United States and, if so, provide a description and the date of any such conviction. 10. Please provide a statement as to the relationship of any of the charitable organization’s officers, directors, trustees, or board members by blood, marriage, or adoption to: (a) each other, or (b) director, agent, or employee of a charitable organization under contract with the professional fundraising counsel or solicitor. 11. Please list (using extra paper if necessary) all charitable organizations with which you have contracted in the State of South Carolina for the previous three years: Name: _______________________________ Address: ____________________________ Name: _______________________________ Address: ____________________________ Name: _______________________________ Address: ____________________________ Name: _______________________________ Address: ____________________________ 12. Please provide name, address, telephone number of registered (authorized) agent for service of process. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ IF APPLICANT HAS A PRINCIPAL PLACE OF BUSINESS OUTSIDE THE STATE OR IS ORGANIZED UNDER AND BY VIRTUE OF THE LAWS OF A FOREIGN STATE AND HAS NOT APPOINTED A REGISTERED AGENT FOR SERVICE OF PROCESS IN THIS STATE, THEN APPLICANT HAS IRREVOCABLY APPOINTED THE SECRETARY OF STATE AS THE AGENT UPON WHOM MAY BE SERVED SUMMONS, SUBPOENA, SUBPOENA DUCES TECUM OR OTHER PROCESS DIRECTED TO APPLICANT FOR ANY ACTION OR PROCEEDING BROUGHT UNDER THE PROVISIONS OF THE SOLICITATION OF CHARITABLE FUNDS ACT. S.C. CODE § 33-56-130 (1976) AS AMENDED. I CERTIFY THAT THE INFORMATION FURNISHED IN THIS STATEMENT AND ALL ATTACHED SUPPLEMENTA RY INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF. FURTHERMORE, I AGREE TO FILE A TRUE COPY OF ALL CONSULTING AGREEMENTS EFFECTIVE IN THE STATE OF SOUTH CAROLINA AT LEAST TEN (10) DAYS BEFORE ANY SOLICITATION ACTIVITY IS BEGUN IN SOUTH CAROLINA. Signature of Chief Executive Officer Print Name of Chief Executive Officer Date of Signature Print Title Rev. 10/8/2033 American LegalNet, Inc. www.USCourtForms.com