Form Bco-170a - Solicitation Notice Addendum Form For Contract
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1(Rev. 6-94)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF STATE
BUREAU OF CHARITABLE ORGANIZATIONS
P.O. BOX 8723
HARRISBURG, PENNSYLVANIA 17105
TELEPHONE: (717) 783-1720
(1) 800-732-0999
SOLICITATION NOTICE ADDENDUM FORM BCO-170A FOR CONTRACT #_____________
Business name and address of Professional Solicitor
Legal name and address of Charitable Organization as
registered with the Department
as registered, unless exempt from registration:
____________________________________________
____________________________________________
(FULL BUSINESS NAME)
(FULL LEGAL NAME)
____________________________________________
____________________________________________
(ADDRESS)
(ADDRESS)
____________________________________________
____________________________________________
(CITY)
(STATE)
(ZIP CODE)
(CITY)
(STATE)
(ZIP CODE)
1.
Provide a description of the solicitation campaign or event to be conducted. Indicate the date the solicitation campaign
or event will begin and terminate within Pennsylvania. If the campaign involves a show, circus, performance or similar event
provide the address and seating capacity of the facility where the event is to be held and the time and date of each
performance:
_______________________________________________________________________________________________________
2.
State the scope of the solicitation campaign or event:
County________ State_________ National__________ International____________
3.
Give a complete description of the charitable program (purpose) for which the event or campaign is to be conducted:
_______________________________________________________________________________________________________
4.
Will you as professional solicitor or anyone acting on your behalf at any time have custody or control of contributions?
Yes_______ No_________
5.
The account number and location of each bank account where receipts from the campaign are to be deposited (may be
required to obtain the information from the charity).
_______________________________________________________________________________________________________
6. Give each location and telephone number from which the solicitation is to be conducted.
_______________________________________________________________________________________________________
7.
The legal name and resident address of each person responsible for directing and supervising the conduct of the campaign
and each person who Is to solicit during such campaign (Attach additional sheet If necessary).
_______________________________________________________________________________________________________
I, the authorized contracting officer for the professional solicitor, do hereby declare that the information contained herein is true and correct to the best of my
knowledge, information and belief.
____________________________________
_______________________________________
AUTHORIZED CONTRACTING OFFICER
TYPE OR PRINT NAME AND TITLE OF
FOR PROFESSIONAL SOLICITOR
AUTHORIZED CONTRACTING OFFICER
DATE_______________
9
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