Form Bco-155 - Registration Statement For Professional Solicitor - 1994

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(Rev. 6-94)

COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF STATE

BUREAU OF CHARITABLE ORGANIZATIONS

P.O. BOX 8723

HARRISBURG PENNSYLVANIA 17105

TELEPHONE: (717) 783-1720

(1) 800-732-0999

REGISTRATION STATEMENT FOR PROFESSIONAL SOLICITOR FORM BCO-155

INITIAL

RENEWAL

CERTIFICATE

FEE

_____ APPLICATION

_______APPLICATION

NUMBER_________________

REMITTED__________________

(CHECK ONE ABOVE)

Business name and address of applicant:

___________________________________________________________________________________________________________________________________

(FULL BUSINESS NAME)

c/o________________________________________________________________________________________________

___________________________________________________________________________________________________

(STREET AND NUMBER)

(CITY)

(STATE)

(ZIP CODE)

(COUNTY)

(AREA CODE) PHONE NUMBER

Name or names, other than item 1, under which you conduct business:

Form of organization:

a. Corporation (State of Incorporation and Date)________________________________

c. Individual__________

b. Partnership ___________

d. Other_____________

If principal place of business is located outside this Commonwealth do you have any offices in Pennsylvania? Yes _____No______

If Yes, attach address(s), telephone number(s) and person(s) in charge of each office.

5. Attach a list of the names and residence addresses of all principals of the organization, including all officers, directors and owners.

6. Provide the name of all persons who supervise any solicitation activity in this Commonwealth.

7. Are any of the owners, directors, officers or employees of the applicant related by blood, marriage or adoption to:

(A) Any other directors, officers, owners or employees of the applicants Yes ________No__________

(B) Any officer, director, trustee or employee of any charitable organization under contract with the applicants

Yes_________No__________

(C) Any supplier or vendor providing goods or services directly or indirectly to any charitable organization under contract with the applicant?

Yes________No____________

If Yes to any of the above, attach list of related individuals with names, business and residence addresses and relationship.

Attach a list providing the name, address and registration certificate number of all charitable organizations for which the applicant is acting as a professional

solicitor with the beginning and ending date of contract. Indicate date on which solicitation activities began or will begin in the Commonwealth pursuant to the

contract Include only those organizations for whom you will be soliciting charitable contributions within this Commonwealth.

Are all current contracts with charitable organizations on file with the Bureau of Charitable Organizations as required under Section 9 (F) of

Solicitation of Funds for Charitable Purposes Act? Yes_______No _______If No, attach copies. Submit only those contracts that will re the solicitation of

charitable contributions within this Commonwealth.