Application to Register as a Professional Solicitor
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1. Name _____________________________________________ 2. The applicant is a: corporation partnership individual 3. Has the applicant ever been known under any name other than that given above? yes no If yes, list each such name:
If address is not in Maryland, give principal Maryland address, if any, where financial records are kept:
5. Telephone ___________ FAX: _____________ E-mail: ______________________ Federal ID or Social Security No. __________________ 6. List all Officers, Directors or Partners Name Title Residential Address
7. List person(s) having more than a 5% financial interest or ownership Name Title Residential Address
PS Application Form - page 2
8. Does the applicant or any officer, director, partner or employee of the applicant or any person holding any financial interest in the applicant, have any interest in any mail house, cashiering or other business with which it or client charitable organization does business pursuant to or in conjunction with a contract between the applicant and the charitable organization? yes ______ no______ If yes, provide details:
9. Is any officer, director, partner or employee of the applicant or any person holding any financial interest in the applicant also an officer, director partner or employee of a charitable organization with which the applicant does business? yes no If yes, provide details:
10. When and where was the applicant organized to do business? Month, day, year ____________________ State _________________ 11. Has the applicant had any license, registration or permit denied, canceled or revoked, or is any such action pending? yes no If yes, provide following information: Name & Address of Date Nature of Action Government Agency
12. Has the applicant ever been enjoined or prohibited from soliciting contributions in any state, including Maryland either personally or as a principal of another entity? yes no If yes, please explain:
PS Application Form - page 3
13. Has the applicant or any principal of the applicant ever been licensed or held a certificate as a professional solicitor or fund-raiser in any other state(s) either personally or as a principal in another entity? yes no If yes, please list states and dates licensed:
14. List the names and addresses of all charitable organizations with which the applicant has contracts to act as a professional solicitor in Maryland. Attach copies of all current contracts.
15. List the names and addresses of all individuals or organizations with which the applicant has subcontracts and the subcontracting agreement furthers the purpose of the agreement between the solicitor and the charity. Attach copies of all current contracts.
16. What type of solicitation program do you plan to use (personal contact, direct mail, telephone, radio, television, etc.)? 17. I acknowledge that the Maryland Secretary of State is deemed to be my agent upon whom may be served any summons, subpoena, subpoena duces tecum or other court process directed to the applicant or any partner, principal officer or director of the applicant. yes no 18. Check One. All taxes due from the applicant to the State or Baltimore City or a county of the State for the preceding fiscal year have been paid, and all taxes the applicant was required to collect and pay over to the State or to Baltimore City or a county of the State for the preceding fiscal year have been collected and paid over. The taxes due from the applicant to the State or to Baltimore City or a county of the State are under dispute and the dispute has not been finally resolved.
PS Application Form - page 4
I hereby consent to the jurisdiction and venue of the Circuit Court of Anne Arundel County in Maryland in actions brought under the Business Regulation Article, Title 6 of the Annotated Code of Maryland, Charitable organizations and Charitable Representative
I solemnly affirm under the penalties of perjury and upon personal knowledge that the contents of the foregoing paper are true.
____________________________________________________________________ (Type or Print) Name of President, Chair or Principal Officer
____________________________________________________________________ Signature of President, Chair or Principal Officer Be certain to include the surety bond or irrevocable letter of credit, any required accounting reports and the fund-raising notice with your application.
For the acounting report, you must use the Adobe Acrobat Reader. You may download this free from the Adobe website.
Only a form issued by the Office of the Secretary of State or printed directly from the Internet will be accepted by the Office of the Secretary of State.