Form Bco-155 - Registration Statement For Professional Solicitor - 1994 Page 2

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10.

Has the organization ever voluntarily entered into any legally enforceable agreement such as an assurance of voluntary compliance or discontinuance with any

District Attorney, Office of Attorney General, local or state governmental agency?

Yes ______ No _________

If Yes, attach copy of such agreement.

11.

Has a license, permit or registration of applicant ever been denied, suspended or revoked by any governmental agency, or are such

proceedings pending? Yes______ No________ If Yes, state reasons for such denial, suspension or revocation and attach copy of such denial, suspension or

revocation.

12.

Has applicant, any officer or director of the applicant, any person with a controlling interest in the applicant, or any person the applicant employs, engages or

procures to solicit for compensation ever been convicted by a court of any state or the United States of any felony, or any misdemeanor involving dishonesty or

arising from the conduct of a solicitation for a charitable organization or purpose?

Yes________ No ________ If Yes, give complete information.

CERTIFICATION AND AFFIDAVIT

STATE OF___________________________

COUNTY OF_________________________

On this day before me, the undersigned notary public in and for the State and County aforesaid, personally appeared

____________________________________________________,Principal Officer, who being duly sworn according to law,

say that all statements made in the foregoing application are true and correct to the best of his or her knowledge, information and

belief.

Sworn and subscribed to before me

this______day of_________, 20____

______________________________