Form Char012 - Professional Solicitor Registration Statement

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Professional Solicitor Registration Statement
Open to Public
CHAR012
Form
New York State Department of Law (Office of the Attorney General)
Inspection
Charities Bureau
The Capitol
Albany, NY 12224
(excluding page 3)
Article 7-A of the Executive Law
Part A - Identification of Professional Solicitor (PS)
1. Full Legal Name of Professional Solicitor (this name must be used when acting as a PS)
2. NYS Professional Solicitor ID# (if any)
___ ___ - ___ ___ - ___ ___
3. Home Mailing Address (Number and Street)
Apartment
4. Home Telephone Number
Number
City or Town, State or Country and ZIP+ 4
5. Home Email Address
6. Work Address (Number and Street)
Room/Suite
7. Work Telephone Number
City or Town, State or Country and ZIP + 4
8. Work Email Address
9. Name of Third Party Representative (relating to this registration and other statutory filings) 10. Primary Contact for Third Party (include title)
Third Party Mailing Address (Number and Street)
Room/Suite
11. Third Party Phone #
12. Third Party Fax #
City or Town, State or Country and ZIP + 4
13. Third Party Email Address
Part B - Certification - Registrant’s Signature Required
, the Registrant, certify under the penalties for perjury, that I have reviewed this Registration Statement, including all schedules and attachments, and to
I
the best of my knowledge and belief, they are true, correct and complete in accordance with the laws of the State of New York applicable to this statement.
PS Registrant
Signature
Printed Name
Title
Date
Part C - Fee and Mailing
Statutory Fee Due:
Submit a check or money order made payable to “NYS
Mail completed form with the required attachments and
$80
Department of Law”.
fee to the address at the top of this page.
Part D - Current Employment as a Professional Solicitor
Enter present employment as a Professional Solicitor (PS) and include appropriate date of solicitation/employment commencement as it relates to this
registration submission.
1. Name of Employing Professional Fund Raiser (PFR)
3. Date Registrant Began/Shall
Begin NYS Solicitation Related
To This Registration Submission:
2. Mailing Address (Number and Street)
Room/Suite
__ __ / __ __ / __ __ __ __
City or Town, State or Country and ZIP+ 4
4. Telephone Number
DATE RECEIVED
FEE RECEIVED
REGISTRATION FILING ID#
PS ID#
PFR ID#
FOR OFFICE
USE ONLY
REVIEWER
ACCEPT DATE
START DATE
END DATE
Page 1 of 3
Form CHAR012 (2010)

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