Contracted Fundraiser Registration Form A.r.s. 44-6554 - Arizona Secretary Of State Page 2
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23. List the states and agencies in which the Contracted Fundraiser conducts fundraising
activities.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
ATTACH ADDITIONAL SHEETS IF NECESSARY
4. Describe below any convictions or pleas of no contest to a felony or misdemeanor
involving fraud, dishonesty, false statement or the receipt or expectation of receipt of
anything of pecuniary value or a violation of A.R.S. Title 44, Chapter 9, Article 6.
Date of Offense: _______________________________________________________
Place of Offense: ______________________________________________________
Nature of Offense: _____________________________________________________
ATTACH ADDITIONAL SHEETS IF NECESSARY
I, the undersigned, swear under penalty of law that the representations made in this
Contracted Fundraiser Registration form are true and accurate.
If the contracted fundraiser is an individual, that individual shall complete the
following:
Printed Name of Contracted Fundraiser: ____________________________________
Signature of Contracted Fundraiser: _______________________________________
If the Contracted Fundraiser is an organization, a person authorized to sign for the
organization shall complete the following:
Printed Name of Representative: _____________________ Title: ________________
Signature of Representative: _____________________________________________
Subscribed and sworn to before me this __________day of ______________, 19____
Notary Public Signature: ___________________ My commission expires: ________
Revised 4-98
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