Form Ss-6003 - Application For Registration Of A Professional Solicitor Page 2
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2Type of Service: _______________________________________________________________
3. Name / Address: _______________________________________________________________
Type of service: _______________________________________________________________
4. Name / Address: ________________________________________________________________
Type of service: ________________________________________________________________
B. Attach a copy of contract(s) or written agreements, signed by two (2) officials 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 ______ No _____.
If “yes”, give the name, date, State, and amount recovered: ________________________________
_________________________________________________________________________________
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 SECTION
I certify that the above statements and all continuation sheets are true and accurate.
_________________________________________
Notary Seal
Signature of Owner / Authorized Officer
Sworn to and Subscribed before me at:
___________________________________
_________________________________________
City / State
Print Name
This ______ day of ______________, 200 ___.
_________________________________________
___________________________________
Title
Notary Signature
_________________________________________
______________________________________
Date
My commission expires: ___________________
SS-6003 (Rev 7/25/07)
RDA 1742
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