Print Form The State of South Carolina Office of the Secretary of State Mark Hammond Pub lic Charities Divison Registration Application for a Professional Fundrais ing Solicitor Date: ____________________________ [ ] Initial Registrati on [ ] Renewal Renewals, ENTER Fundraiser Registration #: ___________ GENERA L 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 us ed by prospective contributors. This office receives numerous requests for in formation from members of the general public who are contemplating making char itable contributions. It is very important, therefore, that you make a full dis closure 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. Professional Solicitors must include a $15,000.00 bond bound unto the Stat e of South Carolina. 2. Enclose a copy of all consulting or fundraising agreeme nts effective in South Carolina. 3. Include a $50.00 filing fee. Make check payable to: "South Carolina Secretary of State.” 4. Notify the Publ ic Charities Division of any changes to this application within 10 days of such c hanges. 5. Mail to: Office of the Secretary of State Public Charities Divison P. O. Box 11350 Columbia, SC 29211 (803) 734-1790 6. Please refer to the Solic itation of Charitable Funds Act, S.C. Code § 33-56-110 et seq. for a seq. complete description of registration requirements. American LegalNet, Inc. www.FormsWorkflow.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 princip al 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:______________________________________ 5. List on a separate sheet of paper the names, addresses and titles of all principal officers, directors, individual owners or partners for the prec eding three years. 6. Are you currently registered in any other state as a Profe ssional Fundraiser, Professional Solicitor, or a Professional Fundraising C ounsel? Yes ____ No ____. If so, list all such states. 7. Do you ever have custod y of contributions or any financial records of contributions of the charitable organization with which you are contracted? ___Yes ___ No. 8. 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. 9. Please provide a statement as to whether the applicant, or its directors, principal officers, individual owners, or partners is or have been the subject of a legal or administrative action, including an injunction concerning a char itable solicitation, fundraising campaign, or campaign with a commercial co- venturer by another local, state, or federal governmental authority includin g, but not limited to registration or license revocation or denial, fines, inju nctions, suspensions, or voluntary agreement to discontinue any charitable s olicitation activity and, if so, a written explanation of those actions. 10. P lease provide a statement as to whether the applicant, or its directors, princi pal officers, individual owners, or partners have been the subject of a crimina l conviction, including guilty or nolo contendere pleas involving fraud, dish onesty, false statement or any violation of any American LegalNet, Inc. www.FormsWorkflow.com charitable solicitations act in any jurisdiction within the United States and , if so, provide a description and the date of any such conviction. 11. Please pr ovide a statement as to the relationship of any of the charitable organization’ s officers, directors, trustees, or board members by blood, marriage, or adopt ion to: (a) each other, or (b) director, agent, or employee of a charitable organizati on under contract with the professional fundraising counsel or solicitor. 12 . Please list (using extra paper if necessary) all charitable organizations wi th which you have contracted in the State of South Carolina for the previous thre e years: Name: _______________________________ Address: _______________ _____________ Name: _______________________________ Address: _________ ___________________ Name: _______________________________ Address: ___ _________________________ Name: _______________________________ Addre ss: ____________________________ 13. Please provide name, address, telephone number of registered (authorized) agent for service of process. ________________________________________________________________________ ________________________________________________ ________________________ 14. Name of Bonding Company___________________ _______Bond Number____________ IF APPLICANT HAS A PRINCIPAL PLACE OF BUSINE SS 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 AM ENDED. I CERTIFY THAT THE INFORMATION FURNISHED IN THIS STATEMENT AND ALL ATTACHED SUPPLEMENTARY INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF. FURTHERMORE, I AGREE TO FILE A TRUE COPY OF ALL CONSULTI NG AGREEMENTS EFFECTIVE IN THE STATE OF SOUTH CAROLINA AT LEAST TEN (10) DAYS BEF ORE ANY SOLICITATION ACTIVITY IS BEGUN IN SOUTH CAROLINA. Signature of Chief Executive Officer Print Name of Chief Executive Officer Date of Signature Print Title X:\FORMS\EXTERNAL\Solicitor Registration.doc Rev. 10/8/2003 American LegalNet, Inc. www.FormsWorkflow.com