Form Char012 - Professional Solicitor Registration Statement (Page 2 of 5) in pdf

PART E - Previous Employment as a PS, PFR or FRC

Prior to the date specified in Part D3, was the Registrant employed as a Professional Solicitor (PS), Professional Fund Raiser (PFR)

or Fund Raising Counsel (FRC)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G Yes* G No

*If “Yes,” complete the following for each previous employment (Include current employment first, if employment began prior to the date specified

in Part D3.)

Mailing Address (number and street, room/suite,

Name of Employing PFR or FRC

city or town, state or country and ZIP + 4)

Dates of Employment

Start date:

__ __ / __ __ / __ __ __ __

End date:

__ __ / __ __ / __ __ __ __

Start date:

__ __ / __ __ / __ __ __ __

End date:

__ __ / __ __ / __ __ __ __

Start date:

__ __ / __ __ / __ __ __ __

End date:

__ __ / __ __ / __ __ __ __

Start date:

__ __ / __ __ / __ __ __ __

End date:

__ __ / __ __ / __ __ __ __

Start date:

__ __ / __ __ / __ __ __ __

End date:

__ __ / __ __ / __ __ __ __

Start date:

__ __ / __ __ / __ __ __ __

End date:

__ __ / __ __ / __ __ __ __

Start date:

__ __ / __ __ / __ __ __ __

End date:

__ __ / __ __ / __ __ __ __

Start date:

__ __ / __ __ / __ __ __ __

End date:

__ __ / __ __ / __ __ __ __

Part F - Previous Conduct

1. In connection with any fund raising activity, has the Registrant ever had any license, registration or permit denied, canceled, suspended or

revoked, or has any official disciplinary or legal action ever been taken, or is one currently pending, against the Registrant? . . . . .

Yes*

*If “Yes,” describe below (include name and address of government agency, nature of outcome and date):

2. Has the Registrant ever entered into any agreement with any regulatory body regarding the Registrant’s conduct in connection with any fund

raising activity? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes*

*If “Yes,” describe below (include name and address of government agency, nature of outcome and date):

3. Has the Registrant ever been convicted of or pleaded guilty to a felony or misdemeanor involving the misappropriation or misuse of the money

or property of another? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes*

*If “Yes,” describe below (include name and address of government agency, nature of outcome and date):

Page 2 of 3

Form CHAR012 (2010)