Form Ss-6003 - Application For Registration Of A Professional Solicitor
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1
2State of Tennessee
WARN ING: F a lse or mis lead ing stat e men ts subject to maximum $5,000 penalty.
T.C.A. §48-101-514
APPLICATION FOR REGISTRATION
Department of State
OF A PROFESSIONAL SOLICITOR
Division of Charitable Solicitations & Gaming
William R. Snodgrass Tennessee Tower
th
312 Eighth Avenue North, 8
Floor
Nashville, TN 37243
ALL REGISTRATIONS EXPIRE DECEMBER 31
(615) 741-2555 / (615) 253-5173 - fax
I N S T R U C T I O N S : T y p e o r p r i n t y o u r a n s w e r s . I f a n a n s w e r d o e s
OFFICE USE ONLY
Reg. No.
Date Received
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
Fee Pd.
bond, payable to the State of Tennessee, must accompany this application.
Rec. No.
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)
(Zip)
B. Mailing Address: _____________________________________________________________________
(Street)
____________________________________________________________________________________
(City)
(State)
(Zip)
C. List address of additional offices / places of operation in Tennessee.
___________________________________________________________________________________
___________________________________________________________________________________
D. Contact Name / Address: ______________________________________________________________
(name)
___________________________________________________________________________________
(Street)
(City/State)
(Zip)
___________________________________________________________________________________
(phone)
(fax)
(email)
3. A. Applicant is and Individual ______ Partnership _______ Corporation _______ Other ______
B. Year organized _______________ State __________________
4. List owners, partners, or corporate officers:
Name
Title
Address
Phone_____
1._______________________________________________________________________________
2._______________________________________________________________________________
3._______________________________________________________________________________
5. A. List all current contracts to solicit funds in Tennessee between the professional solicitor 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: _______________________________________________________________
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