Free ss-6040 (4-09).indd - Tennessee

State of Tennessee

WARNING: False or misleading statements subject to maximum $5,000 penalty. T.C.A. §48-101-514

Department of State
Division of Charitable Solicitations & Gaming

William R. Snodgrass Tennessee Tower 312 Rosa L. Parks Avenue, 8th Floor Nashville, TN 37243 (615) 741-2555 / (615) 253-5173 fax

APPLICATION FOR REGISTRATION OF A PROFESSIONAL FUNDRAISING COUNSEL
ALL REGISTRATIONS EXPIRE DECEMBER 31
OFFICE USE ONLY
Reg. No. Fee Pd. Rec. No. Date Received

INSTRUCTIONS: Type or print your answers. If an answer does not apply, write "N/A." Attach additional sheets if you are unable to answer in the space provided. A nonrefundable registration fee of $250.00 payable to the State of Tennessee, must accompany this application. 1. A. Name of organization:

B. List other names you currently use or previously used to conduct business and attach documents authorizing such use:

C. Federal Employer Identification Number: D. Contact Name / Address:
(Name) (Street) (Phone) (Fax) (City/State) (Email) (Zip)

2. A. Principal Address:
(Street) (City) (State) (Zip)

B. Mailing Address:
(Street) (City) (State) (Zip)

C. List address of additional offices / places of operation in the State:

3. A. Applicant is an Individual B. Year organized 4. State

Partnership

Corporation

Other

List corporate officers and directors of corporation or unincorporated association; each partner in the partnership; or owner in sole proprietorship.

Name 1. 2. 3.

Title

Address

Phone

5. A. List all current contracts to solicit funds in Tennessee between the fundraising counsel and nonprofit organizations. Describe the type of service provided. (e.g., telemarketing, direct mail, Internet, etc.) 1. Name / Address: Type of service: 2. Name / Address: Type of Service: 3. Name / Address: Type of service: 4. Name / Address: Type of service: B. Attach a copy of contract(s) with charitable organizations soliciting from or within Tennessee, signed by one (1) official of the charitable organization and one (1) officer of your company. 6. Are any individuals, partners, officers, directors, or managing agents affiliated with, controlled by, or have control over, either directly or indirectly, any nonprofit organization listed in #5 above? Yes No If yes, list the name of the individual / partner / officer and the controlled organization. List the other states where applicant is registered:

7.

8. A. Has the applicant: (1) had any license, registration, or permit revoked or denied or (2) been enjoined or prohibited from soliciting contributions? If "yes", describe the action, date, and place of the action:

9.

Disclose any civil administrative or other legal action filed against applicant pursuant to any State or local charitable solicitations act, including the complete case style, summary, and disposition of the action:

Signature This document must be signed by an authorized officer. I certify that the statements in this registration statement and all supplemental forms, documents, and continuation sheets are true and correct to the best of my knowledge and belief.

Signature

Print Name

Title

Date
SS-6040 (Rev. 4/09) RDA 1742