Free Solicitation Campaign Notice - Tennessee

Print Form

State of Tennessee

W A R N ING: Fa l se or m i s lea d in g st ate me nt s subject to maximum $5,000 civil 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

SOLICITATION CAMPAIGN NOTICE

_______________________________________________________________________________
INSTRUCTIONS: Prior to the commencement of each solicitation campaign, a completed solicitation notice form shall be filed by a professional solicitor with the Secretary of State. Within three (3) days after any modifications or changes in the required information, the Secretary shall be notified by the professional solicitor of those modifications or changes. If you are unable to answer in the space provided, attach additional sheets. LABEL ALL ATTACHMENTS ACCORDING TO APPLICABLE PART AND ITEM NUMBER. PLEASE PRINT OR TYPE.

________________________________________________________________________________ Part I 1. Name of Professional Solicitor: ____________________________________________________________
2. Name of Charitable Organization on whose behalf the campaign is being conducted: _________________ _____________________________________________________________________________________ 3. Beginning and ending dates of this campaign: ________ _____ _______
Month Day Year THROUGH

_______ _____ _____
Month Day Year

Note: If the campaign lasts more than one year, a financial report shall be filed within ninety (90) days after the fiscal year end of any campaign, as well as at the completion of the campaign.

4. Location where campaign will be conducted: _________________________________________________
Street

_____________________________________________________________________(___)____________
City State Zip Telephone

5. Attach a list of the names and resident addresses of all employees or other individuals who will be working in connection with this campaign. 6. Have any of the employees been convicted of a felony in the last five (5) years? Yes



No



7. Please provide all bank account numbers and the location of all bank accounts where receipts from the campaign will be deposited: ____________________________________________________________________________________ ____________________________________________________________________________________

8. Do you intend to utilize a subcontractor to solicit contributions?

Yes No If yes, list name: ________________________________________________________________________ Note: Subcontractor must be registered as a professional solicitor with this office.

9. What type of fund raising will be conducted during this particular campaign?

Direct mail

Door to Door

Telemarketing

Other (Please describe) _________________

10. Does the professional solicitor have a contractual agreement with the charitable organization which provides that the professional solicitor shall not have access to the funds raised and shall not make deposits to, or have signature authority or any other authority over the charitable organization's bank accounts? Yes



No



If yes, cite the contract provision or section: ________________________

Part II
T.C.A. § 48-101-513 requires the professional solicitor to submit certain documents prior to beginning any solicitation campaign. Indicate whether or not a document is attached by marking the appropriate box.
Attached Not Attached

1. A true copy of any contract or written agreement which sets forth all of the terms of the campaign. 2. The text of any oral solicitations made to the public. 3. Samples of any campaign literature including written pledge receipts, tickets or any solicitations and written confirmations. The samples may be voided.

________________________________________________________________________________ Signature Section
I certify that the information furnished in this document and all other attachments is true to the best of my knowledge.
____________________________________________ Signature of Authorized Officer of Professional Solicitor ____________________________________________ Print Name ____________________________________________ Title ____________________________________________ Date _______________________________________________ Signature of Authorized Officer of Charitable Organization _______________________________________________ Print Name _______________________________________________ Title _______________________________________________ Date

SS-6020 (Rev. 3/24/09)

RDA 1742