PUBLIC SAFETY ORGANIZATION, INDEPENDENT PROMOTER, OR PUBLIC SAFETY PUBLICATION SOLICITOR'S REGISTRATION STATEMENT ____New ____Renewal 1. (Please print or type. Use additional sheets of paper if necessary.) Name of solicitor:__________________________________________________________ Street Address:____________________________________________________________ City: ___________________________ State: ________ Zip: ____________ 2. Mailing Address (if different from above): _________________________________________________________________________ 3. 4. Telephone number: (______) _________________________ List below the name, street and mailing address, and telephone number of each public safety organization, independent promoter, or public safety publication on whose behalf you solicit or will solicit in this state. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 5. If the solicitor is not a resident of Texas, attach an irrevocable written consent form appointing the secretary of state as agent for service of process on the solicitor for any action pertaining to a violation of this act. Executed this ____________ day of _____________________________, ____________. __________________________________ (Signature) __________________________________ (Printed Name & Title) Form #3203 American LegalNet, Inc. www.FormsWorkFlow.com