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Application For Professional Fundraiser Form - Rhode Island Department Of Business Regulation

STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS

DEPARTMENT OF BUSINESS REGULATION

SECURTIES DIVISON

CHARITABLE ORGANIZATIONS SECTION

1511 PONTIAC AVENUE

JOHN O. PASTORE CENTER, 69-1

CRANSTON, RI 02920

APPLICATION FOR PROFESSIONAL FUNDRAISER

FILINGS MUST BE SUBMITTED ON

CD-ROM. WE NO LONGER ACCEPT PAPER FILINGS

E-mail Address______________________

INITIAL APPLICATION

EIN #: ________________________

RENEWAL APPLICATION

ANNUAL FEE: $240

CHECKS PAYABLE TO: GENERAL TREASURER STATE OF RI

ANNUAL EXPIRATION: JUNE 30

1. NAME OF ORGANIZATION: _____________________________________________________________

2. ADDRESS: ____________________________________________________________________________

3. DATE/PLACE OF ORGANIZATION: ______________________________________________________

4. FORM OF ORGANIZATION: _____________________________________________________________

5. ATTACH BOND, if required by R.I.G.L. 5-53.1-8.

6. SUBMIT COPIES OF ALL CONTRACTS WITH CHARITABLE ORGANIZATIONS.

(Must be submitted within ten (10) days after signing, pursuant to R.I.G.L. 5-53.1-9)

7. ATTACH NAMES AND ADDRESSES OF ALL OFFICERS, AGENTS & EMPLOYEES.

8. CONTACT PERSON AND MAILING ADDRESS: _____________________________________________

__________________________________________________________________________________________

I CERTIFY UNDER PENALTY OF PERJURY THAT I HAVE READ THIS APPLICATION AND KNOW

THAT ALL STATEMENTS THEREIN ARE TRUE.

_____________________________________

_________________________

(Signature)

(Date)

_______________________________________________________________

(Print Name, title and Phone Number)

NOTARY:

(PROFESSIONAL FUNDRAISER FORM)

(REV. 4/2008)

Application For Professional Fundraiser Form - Rhode Island Department Of Business Regulation