STATE OF WEST VIRGINIA Registration Statement of Professional Fund Raiser or Fund-Raising Counsel Send Registration Statement, fee, bond and supporting documents to: Secretary of State State Capitol Room 157-K Charleston, WV 25305 Phone: (304) 558-6000 Fax: (304) 558-0900 Instructions West Virginia Code § 29-19-9 provides that no person may act as a professional fund- raising counsel or professional solicitor unless he or she is first registered and bonded with the Secretary of State. 1. 2. 3. 4. 5. 6. 7. Please complete all items which are applicable to your organization. The registration must be signed and notarized. All professional fund raisers and fund-raising counsels are required to send a registration fee of $100. Checks should be made payable to the Secretary of State. All professional fund raisers and fund-raising counsels are required to file a $10,000 bond on the form provided with this registration which must be approved by the Attorney General’s office. Every written contract or agreement between professional fund-raising counsels or solicitors and charitable organizations must be filed with the Secretary of State within ten days after the parties have entered into such an agreement (§29-19-7). An extension of time to file an annual registration or report must be requested in writing before the registration expiration date. For good cause, the Secretary of State will extend the due date for a period not to exceed 90 days. [§20-19-5 (e)]. Organizations failing to file a registration by the original or extended due date will be required to pay an additional late fee of $25 for each month or part of a month the filing is late [§29-19-5(f)]. Copies of all scripts and solicitation materials used to solicit funds in West Virginia must be submitted to the Secretary of State. American LegalNet, Inc. www.USCourtForms.com REGISTRATION STATEMENT New Registration Renewal Professional Fund Raiser Professional Fund-Raising Counsel 1. 2. 3. 4. 5. 6. Date Name of Business: Street Address: Mailing Address: City: State: Phone: Fax: Principal West Virginia Address, if different from above: Zip: Phone: 8. Sole Proprietorship Corporation Date and Place business entity was organized or incorporated: 9. List all DBA’s used by the business entity: 10. Names and addresses of all individuals, partners, officers and principal salaried staff: 11. Names and addresses of all employees operating in or soliciting in West Virginia: (Attach list if necessary.) 12. Names and addresses of all sub-contractors responsible for soliciting in West Virginia: 13. Give location of all telemarketing operations in West Virginia: 7. Type of Business Entity: Partnership Other American LegalNet, Inc. www.USCourtForms.com 14. List all mailing addresses, including Post Office Boxes, to be employed in the solicitation of funds in West Virginia. 15. List names and addresses of all charitable organizations with which the organization has contracts to act as professional fund raiser or fund-raising counsel, in this state: (Give name and full address of each Charitable Organization) 1. 2. 3. 4. 5. 16. Terms of Remuneration Per Contract: 1. 2. 3. 4. 5. 17. Are all current contracts with charitable organizations on file in this office as required by law? Yes No 18. List the names and addresses of professional solicitors employed by the organization, in West Virginia and the terms of remuneration. 1. 2. 3. 19. Is the organization licensed by, registered with, or have a permit from any other governmental agency for the purpose of soliciting funds for charitable organizations in any state? Yes No If yes, give the following information: Names: 1. 2. 3. City: State: American LegalNet, Inc. www.USCourtForms.com Date of Authorization: Month: 1. 2. 3. Day: Year: 20. Has the organization had any license, registration or permit denied, cancelled or revoked in any state? Yes No If yes, give the following information: Name and address of the authority taking action and the nature and date of the disciplinary action: 21. Has any official disciplinary action, other than the actions listed in Item 20, and including court action, been taken against the organization of any members, employees, officers or directors in any state? Yes No If yes, give the following information: Name and address of government agency and the nature and date of the action: I hereby certify under oath that all answers and statements given by me are true and correct without reservation of any kind. It is understood that all facts in this application are open to thorough investigation. (Date) (Signature of Applicant) (Title) State of County of Subscribed and sworn before me this day of , My Commission Expires (Year) . Notary Public PRINT OR SAVE THIS COPY, THEN CLICK HERE TO RESET. American LegalNet, Inc. www.USCourtForms.com