Form Ss-6040 - Application For Registration Of A Professional Fundraising Counsel

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WARNING: False or misleading statements subject to
State of Tennessee
maximum $5,000 penalty. T.C.A. §48-101-514
APPLICATION FOR REGISTRATION OF A
Department of State
PROFESSIONAL FUNDRAISING COUNSEL
Division of Charitable Solicitations & Gaming
William R. Snodgrass Tennessee Tower
312 Rosa L. Parks Avenue, 8th Floor
ALL REGISTRATIONS EXPIRE DECEMBER 31
Nashville, TN 37243
(615) 741-2555 / (615) 253-5173 fax
For Office Use Only
INSTRUCTIONS: Type or print your answers. If an answer does not apply, write
Received
Reg. No.
“N/A.” Attach additional sheets if you are unable to answer in the space provided. A
nonrefundable registration fee of $250.00 payable to the State of Tennessee, must
Fee Pd.
accompany this application.
Rec. No.
1. A. Name of organization:
B. List other names the organization uses to conduct business and, if applicable, attach documents
authorizing such use:
C. Federal Employer Identification Number:
D. Contact Name:
Address:
City:
State:
Zip Code:
Phone:
Fax:
Email:
2. A. Principal Address:
City:
State:
Zip Code:
B. Mailing Address:
City:
State:
Zip Code:
C. List address of additional offices / places of operation in the Tennessee:
Street:
City:
State:
Zip Code:
Street:
City:
State:
Zip Code:
3. A. Applicant is a Sole Proprietor
Partnership
Corporation
Other
B. Year organized
State
4. List corporate officers and directors of corporation or unincorporated association; each partner in the partnership; or
owner in sole proprietorship.
1.
Name:
Title:
Address:
Phone:
2.
Name:
Title:
Address:
Phone:
3.
Name:
Title:
Address:
Phone:
5. Attach a list containing the name and address of each charitable organization soliciting from or within Tennessee,
for which the applicant is providing fundraising counsel services.

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