Long Form Cri-150ic - Initial Registration Statement printable pdf download

Long Form Cri-150ic - Initial Registration Statement

State of New Jersey

& P

EPARTMENT OF

UBLIC

AFETY

IVISION OF

ONSUMER

FFAIRS

FFICE OF

ONSUMER

ROTECTION

& I

HARITIES

EGISTRATION

NVESTIGATION

ECTION

124 H

, PO B

45021

ALSEY

TREET

, NJ 07101

EWARK

(973) 504–6262

Long Form Initial Registration Statement CRI-150IC

Confidential Information

Organization Name ___________________________________________________________________________

1. Are any of the organization’s officers, directors, trustees or five most highly compensated employees related by

blood, marriage or adoption to:

each other?

Yes

b. any officers, agents, or employees of any fund-raising counsel or independent paid fund raiser under

contract to the organization?

Yes

c. any chief executive, employee, any other employee of the organization with a direct financial interest in the

transaction, or any partner, proprietor, director, officer, trustee, or to any shareholder of the organization with

more than two (2) percent interest in any supplier or vendor providing goods or services to the organization?

Yes

2. List the following information for each officer, director, trustee and the five most highly compensated executive

staff employees: (Attach a separate sheet if needed.)

Name

Title

Home address

Telephone number

Relationship

Include area code

______________________________________________________________________________________

3. Signature ________________________________________

Long Form Cri-150ic - Initial Registration Statement

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