Washington State Unified Registration Statement Addendum Form (Page 3 of 3) in pdf

Washington State Unified Registration Statement Addendum Form Page 3

REQUIRED ATTACHMENTS

Please clearly label the attachments that correspond with the following questions

(A) Does the organization, or a commercial fundraiser operating on its behalf, use any other mailing, street, electronic or Internet

addresses (excluding those provided above) to conduct solicitations in Washington State? (check one)

Yes - Attach a list of other addresses used, including those used by commercial fundraisers, if any.

(B) Is the charitable organization a chapter, subsidiary, branch, affiliate, related foundation or supporting organization of a superior or

parent organization? (check one)

Yes - Attach a list of superior or parent organizations. Include the Federal EIN, mailing address, email address, and web address for

each superior/parent listed.

SECTION 3 - SIGNATURE (Required)

By signing this addendum, the applicant: ( a ) certifies that the information contained in the application and in the attachments are

accurate and true to the best of the applicant s knowledge; ( b ) irrevocably appoints the Secretary of State to receive process (notice of

lawsuits) in non-criminal cases against the applicant, and under the conditions set out in RCW 19.09.305; and ( c ) certifies that neither

the organization nor any of its officers, directors, and principals have been convicted of a crime involving charitable solicitations, nor

been subject to permanent injunction or administrative order under the Washington Consumer Protection Act (Chapter 19.86 RCW) in

the past ten years.

_____________________________________

____________________________________

_______________________

________________

Signature of applicant

Printed name

Title

Date

This form may be signed by the President, Treasurer or a comparable officer or, in the absence of officers, person responsible for the organization.

NOTE: Expedited Mail Service is available for registration documents requiring 48-hour turnaround. To utilize Expedited Mail

Service, please enclose $20 per registration document (in addition to regular fees), check ( ) the box on page one of this document,

and write the word EXPEDITE in large, bold letters on the outside of the envelope. Your request will be processed and mailed

within TWO business days of receipt by the Charities Program

URS Addendum/Rev 10/07

Washington State Unified Registration Statement Addendum Form Page 3