Fund-Raising Counsel Application For Registration Form - Office Of The Attorney General Page 2
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5THIS APPLICATION IS:
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NEW (FEE REQUIRED)
RENEWAL (FEE REQUIRED)
INFORMATION CHANGE ONLY (NO FEE REQUIRED)
1.
___________________________________________________________________________________________
LEGAL NAME OF FUND-RAISING COUNSEL
____________________________________________________________________________________________
ANY PREVIOUS LEGAL NAME(S)
2. ______________________________________________________________________________________________
PHYSICAL ADDRESS
CITY
STATE
ZIP CODE
______________________________________________________________________________________________
MAILING ADDRESS (if different from physical)
CITY
STATE
ZIP CODE
3.
____________________________________________________
(_____)________-_______________________
DESIGNATED CONTACT PERSON
TELEPHONE NUMBER
FOR CORRESPONDENCE
_____________________________________________________________________________________________
MAILING ADDRESS
CITY
STATE
ZIP CODE
__________________________________________________
DESIGNATED CONTACT PERSON’S E-MAIL
4.
Names of programs or promotions, aliases, and/or fictitious name(s) for your operation:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
5.
Other name(s), alias(es), and/or fictitious name(s) by which you have ever been known:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
6.
Have you ever had your registration or renewal denied, suspended, revoked, or enjoined by any governmental authority
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or any court?
NO
YES. If so, explain in detail and attach a copy of any such judgment, notice, or order:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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7.
Have you ever been sued for fund-raising-related activities?
NO
YES. If so, explain in detail and attach
a copy of any such judgment, notice and/or order for such occurrence: ____________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
8.
Have you ever entered into, or been subject to, any assurance of voluntary compliance, cease and desist order, or
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private settlement with a government authority?
NO
YES. If so, explain in detail and attach a copy of any
such document: _______________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
9.
Have you (if you are an individual) ever been charged, arrested and/or convicted of a crime other than a simple
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traffic violation?
NO
YES. If so, state the charge(s), the state(s) involved, and, if convicted, attach a copy of
each relevant judgment or court order: _____________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
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