Free 11303.01-06.xft - North Dakota

COMPLETE, PRINT, SIGN IN FRONT OF NOTARY AND MAIL

FOR OFFICE USE ONLY ID# WO# Approved By Issued By

PROFESSIONAL FUNDRAISER REGISTRATION
SECRETARY OF STATE
SFN 11303 (01-06)

FEE: $100.00
Instructions: 1. For reference, see North Dakota Century Code, Section 50-22. 2. Please type or print, complete all blanks, and enter "None" when appropriate. 3. If more space is needed for any section, please add a separate sheet providing the same information requested in those sections. 4. All new contracts, entered into after filing this application, must be filed in the Secretary of State's Office. 5. Must attach a bond in the sum of twenty thousand dollars. 1.

Secretary of State State of North Dakota 600 E Boulevard Ave Dept 108 Bismarck ND 58505-0500 Telephone 701-328-3665 Toll Free 800-352-0867 Ext 83665 Fax 701-328-1690 Web Site: www.nd.gov/sos
Telephone #

Full Legal Name of Business or Individual Applicant Street & mailing address of principle office The business is a: State of Origin City

State Federal ID #

Zip Code

Single Proprietorship

Partnership

Corporation

Limited Liability

First year organized

Business conducted by firm other than professional fundraising 2. If Individual or Partnership, complete all information below. If a Corporation, give information below concerning officers, directors, executive personnel and owners of ten percent or more of the capital stock. *If any person listed has been involved in any civil or criminal litigation, please attach a statement of your summary of the litigation, the outcome, and the parties involved. Full Name Residence Address (City, State, Zip Code) Drivers License # State Where Issued Title or Relationship to Business Birth Date Birth Place Home Telephone # Social Security # *Criminal Record? Yes No Home Telephone # Social Security # *Criminal Record? Yes No Home Telephone # Social Security # *Criminal Record? Yes No Home Telephone # Social Security # *Criminal Record? Yes No Telemarketing Newspaper Magazines or Periodicals Membership Enrollment Telephone # City State Zip Code

a.

Alias(es) Used (If none, so state)

b.

Full Name Residence Address (City, State, Zip Code) Drivers License # State Where Issued

Title or Relationship to Business Birth Date Birth Place

Alias(es) Used (If none, so state)

c.

Full Name Residence Address (City, State, Zip Code) Drivers License # State Where Issued

Title or Relationship to Business Birth Date Birth Place

Alias(es) Used (If none, so state)

d.

Full Name Residence Address (City, State, Zip Code) Drivers License # State Where Issued

Title or Relationship to Business Birth Date Birth Place

Alias(es) Used (If none, so state)

3.

Type of fundraising to be conducted in North Dakota. Check all that apply to your organization. Mail Personal Contact Vending Business Grant writing Radio Television National Show or Concert Other (please describe) Local

4.

Name of auditor accountant, employee, agent or other person who maintains or possesses professional fundraisr's records. Name Address

SFN 11303 (01-06) Page 2

5.

List all officers, agents, or employees employed to work under applicant's direction. You must update this list as changes occur. Attach an additional sheet if necessary. TERMS OF COMPLETE MAILING ADDRESS NAME REMUNERATION STREET CITY STATE ZIP CODE

a. b. c. d. e.

6.

List other professional fundraisers with which any owner, partner or officer were previously associated. NAME OF PROFESSIONAL FUNDRAISER STREET COMPLETE MAILING ADDRESS CITY STATE ZIP CODE TELEPHONE #

a. b.

7.

List all charitable organizations with which applicant has contracts to act as professional fundraiser in North Dakota. A professional Fundraiser may not solicit on behalf of a charitable organization that is not registered. NAME OF CHARITABLE ORGANIZATION SOLICITATION LICENSE # CONTACT PERSON TELEPHONE #

a. b.

8.

List other state/local licenses/registrations/permits to solicit funds for charitable organization. GOVERNMENT AGENCY STREET COMPLETE MAILING ADDRESS CITY STATE ZIP CODE

DATE OF AUTHORITY (MO/DA/YR)

a. b.

9.

Licenses/Registrations/Permits Denied, Canceled or Revoked in any other state (If NONE, Indicate with N/A below) ISSUED BY (AGENCY) CITY STATE Denied REASON Canceled Revoked DATE OF ACTION

I hereby make application as a professional fundraiser in the State of North Dakota. I certify the statements made herein to be true and complete, and are made for the purpose of complying with the requirements of North Dakota Century Code, Section 50-22.

State of ______________________________ County of ____________________________

Signature and Title of Professional Fundraiser

The foregoing instrument was acknowledged before me this _____________ day of ______________________________, 20 __________.

(Notary Seal/Stamp)

Notary Public My Commission Expires_____________________________