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Charitable Organization Registration Statement Form - Wisconsin Department Of Safety And Professional Services

Wisconsin Department of Safety and Professional Services

Mail To:

P.O. Box 8935

1400 E. Washington Avenue

Madison, WI 53708-8935

Madison, WI 53703

FAX #:

(608) 261-7083

E-Mail: dsps@wi.gov

Phone #:

(608) 266-2112

Website:

DIVISION OF PROFESSIONAL CREDENTIAL PROCESSING

CHARITABLE ORGANIZATION REGISTRATION STATEMENT

Name of Organization

Other Names Used for Soliciting

Daytime Telephone Number

(

) ________ - _____________

Address

(Number, Street, City, State, Zip Code)

If the above organization has any offices in Wisconsin, please provide the address and telephone number of

each office, or, if the charitable organization does not have an address, please list the name, address and

telephone number of the person or persons having custody of its financial records.

Type of Organization

Individual

Corporation

Partnership

Other:

________________________________

Date Incorporated or Established and Location

Check here if non-stock

Not-for-Profit Corporation

Month and day on which your fiscal year ends:

_________________________________________________

For Receipting Use Only

APPLICATION FEE:

Please make checks payable to the Department of

Safety and Professional Services. Attach check to

this application.

$15.00 Initial Credential fee

For Office Use Only

Registration Number

Registration Date

#296 (Rev. 8/13)

Ch. 440.41, Stats.

Page 1 of 4

Committed to Equal Opportunity in Employment and Licensing

Charitable Organization Registration Statement Form - Wisconsin Department Of Safety And Professional Services

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