Charitable Organizations Application Form (Page 3 of 4) in pdf

Charitable Organizations Application Form Page 3

10.

Form of organization: _______________________________________________

11.

Tax exempt status under Internal Revenue Code: ______________________

______________________________________________________________

12.

A general description of all the uses for which contributions to be solicited will be

used:_____________________________________________________________

_______________________________________________________________

13.

Date fiscal year ends: ________________________________________________

14.

Other states where licensed:___________________________________________

15.

Has any government agency or court enjoined the applicant, its directors,

members, trustees or senior level executives from soliciting contributions?

Yes ____

No ____ If yes, please describe: ____________________________

__________________________________________________________________

16.

Has applicant’s license or registration been suspended or canceled by any

governmental agency. Yes ____ No ____ If yes, please describe:

__________________________________________________________________

17.

Name and address of any professional fundraisers or fundraising counsel (and

please

submit

copy

the

contracts

for

services):

__________________________________________________________________

18.

(a) State the percentage of contributions received in the immediately preceding

year which was spent for fund raising and administration: __________________

(b) If the exact percentage of contributions received in the immediately preceding

Charitable Organizations Application Form Page 3