Free ss-6003 (4-09).indd - Tennessee

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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 SOLICITOR
ALL REGISTRATIONS EXPIRE DECEMBER 31

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 $800.00 and a $25,000 bond, payable to the State of Tennessee, must accompany this application. 1. A. Name of organization: B. List other names currently or previously used to conduct business: C. Federal Employer Identification Number: 2. A. Principal Address:
(Street) (City) (State) (Street) (City) (State)

OFFICE USE ONLY
Reg. No. Fee Pd. Rec. No. Date Received

(Zip)

B. Mailing Address:
(Zip)

C. List address of additional offices / places of operation in Tennessee.

D. Contact Name / Address:
(Name) (Street) (phone) (fax) (City/State) (email) (Zip)

3. A. Applicant is and Individual B. Year organized 4.

Partnership State

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 contributions from or within Tennessee between the professional solicitor and charitable 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 the contract(s) with those listed in 5A, signed by one (1) official of the charitable organization and one (1) officer of the professional solicitor's organization. 6. Are any individuals, partners, officers, directors, or managing agents affiliated with, controlled by, or have control over, 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.

7. List the name(s) and address(es) of third parties (e.g., "cagers") who will have custody and control over funds solicited during the campaign:

8. List the other states where applicant solicits contributions:

9. 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: B. Has anyone recovered from any of the applicant's surety bonds? Yes If "yes", give the name, date, State, and amount recovered: No

10. Have any individual owners, partners, or corporate officers been convicted of a felony? Yes No If "yes", list the name, criminal offense, date, and place of the conviction:

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-6003 (Rev. 4/09) RDA 1742