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8. A. Is organization currently registered in any other state(s)?

B. If "yes," which state(s)?

9. A.What is the name and address of your parent or national organization?_____________________________________

_____________________________________________________________________________________________

B. List the Chief Executive Officer of your parent or national organization.

Full Name

(Last Name, First Name, M.I. and Title)

_____________________________________________________________________________________________

10. A. Is organization currently authorized by any Tennessee Municipal authority to solicit contributions? Yes

B. If answer is "Yes", list the municipal authorities:

11. A. Has organization ever been enjoined or prohibited from soliciting contributions?

Yes

B. If answer is "Yes", attach a detailed explanation

Explanation attached.

12. A. Has any officer, director, manager, operator, principal or control person of the organization been

the subject of an injunction, judgment or administrative order or been convicted of a felony?

Yes

B. If answer to is "Yes", attach a detailed explanation

Explanation attached.

13. A. Indicate method(s) by which solicitations will be made: Personal Contact

Mail

Telephone

Volunteers

Radio/Television Appeals

Members

Professional Solicitor

Fund Raising Counsel

Vendor

Internet Address

__________________________ Other(s)(Specify)

B. List names, addresses and phone numbers of any professional solicitor, fund raising counsel, vendor or any other

person(s) who, for financial or other consideration, is engaged in solicitation activities on behalf of your organization.

Full Name

Address

Phone

(Last Name, First Name, M.I.)

(Include Street, City, State, Zip)

______________________________________________________________________________________________

C. Attach a true copy of any contract or agreement with any professional solicitor, fund raising counsel, vendor or

any other person(s) involved with the solicitation of contributions. Number of contracts attached:____________

14. A. List names, addresses and phone numbers of all individuals who have final responsibility for custody of contributions.

Full Name

Address

Phone

(Last Name, First Name, M.I.)

(Include Street, City, State, Zip)

_______________________________________________________________________________________________

B. List all bank names and addresses where solicited funds will be deposited.

Full Name

Address

(Include Street or Rural Route, City, State, Zip)

______________________________________________________________________________________________

15. List names, addresses and phone numbers of all individuals responsible for final distribution of contributions.

Full Name

Address

Phone

(Last Name, First Name, M.I.)

(Include Street, City, State, Zip)

______________________________________________________________________________________________

16.

For what purpose will contributions be used? (Be Specific)

SIGNATURE SECTION

This document must be signed by two separate authorized officers in the presence of a Notary Public. Two signatures from the same

individual cannot be accepted.

I/We certify that the information furnished in this application and all continuation sheets is true and correct to the best of my/our knowledge.

Additionally, I/We understand that registration does not imply approval by the state of Tennessee and that any statement indicating

otherwise is a violation of Tennessee law.

_____________________________

_____________

_____________________________

_____________

Signature of Authorized Officer

Date Signed

Signature of Authorized Officer

Date Signed

Charitable Organization

Print Name

Title

NOTARY SEAL

SWORN TO AND SUBSCRIBED BEFORE ME AT:

______________________________________________

(County and State)

This ___________ Day of _______________,19______

_______________________________________________

Signature of Notary Public

My Commission Expires: ______________

SS-6001 (Rev. 2/00)

RDA 1745

Page 2 of 2

Destroy Prior Editions

Form Ss-6001 - Application For Registration Of A Charitable Organization - Departament Of State, State Of Tennessee Page 2

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