Form Ps - Professional Solicitor Application
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1
2Contact Information
KANSAS SECRETARY OF STATE
PS
Kansas Secretary of State
Professional Solicitor Application
Ron Thornburgh
90-06
Memorial Hall, 1st Floor
All information must be completed or this document will not be accepted for filing.
120 S.W. 10th Avenue
Topeka, KS 66612-1594
(785) 296-4564
Print
Reset
Please complete the form, print, sign and
1. Name of professional solicitor:
mail to the Kansas Secretary of State with
the filing fee. Selecting 'Print' will print the
2. Address:
form and 'Reset' will clear the entire form.
Street address
City
State
Zip
Do not write in this space
3. Name of professional fund raiser:
4. Address:
Street address
City
State
Zip
5. Date of Application:
Month
Day
Year
6. I agree to abide by the disclosure requirements of Kansas law, specifically, K.S.A. 17-1766, as set forth below.
All solicitations by professional solicitors shall contain the following disclosures at the point of solicitation:
(a) The name, address and telephone number of the charitable organization;
(b) the registration number, obtained pursuant to K.S.A. 17-1763 for the charitable organization;
(c) if the solicitation is made by a person acting as a professional solicitor, the registration number obtained pursuant to K.S.A.
17-1765; and
(d) that an annual financial report required by K.S.A. 17-1763 for the preceding fiscal year is on file with the secretary of state.
I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct.
Executed on the ________ of ___________ , _____________ .
Day
Month
Year
Signature of applicant
Signature of professional fund raiser
Instructions
1. Please be sure to enclose the $25 filing fee made payable to the secretary of state with the
form. Please do not send cash.
2. This registration/re-registration shall be for a period of one year, or a part thereof, expiring on the 30th
day of June and may be renewed upon written application for additional one-year periods.
Notice: There is a $25 service fee for all returned checks.
K.S.A. 17-1765
Rev. 8/11/03 jb
Rev. 4/20/05 jls
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