Fund-Raising Counsel Application For Registration Form - Office Of The Attorney General Page 4
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517.
Provide the name, date of birth, residence street addresses, mailing addresses (if different), and residence
telephone numbers of all officers, directors, partners, managers, and supervisors of the fund-raising counsel:
(Attach additional sheets if necessary.)
__________________________________________________________________________________________
Name
Title
Date of Birth
__________________________________________________________________________ (___)__________
Address
City
State
Zip Code
Telephone Number
__________________________________________________________________________________________
Name
Title
Date of Birth
__________________________________________________________________________ (___)___________
Address
City
State
Zip Code
Telephone Number
I swear and/or affirm, under penalty of law, that the representations made in this application are true and
accurate.
________________________________________________________________________
Legal Name of Fund-Raising Counsel
By:
_____________________________________________________________________________
Signature
______________________________________________________________________________
Printed Name
_______________________________________________________________________________
Title/Official Position
NOTARY
STATE OF_______________
)
) SS.
COUNTY OF _____________
)
Subscribed and sworn to, before me, a Notary Public in, and for, said County and State, this _______ day of
________________, 20____.
My Commission Expires:
_______________________________________________________
______/______/_____
Signature of Notary Public
_______________________________________________________
County of Residence
Printed Name
__________________
STAMP or SEAL:
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