Looking for a Massachusetts Legal Forms And Templates? Download it for free!

Form 10a - Form Of Addendum To Registration Statement To Be Filed By Professional Solicitors Page 2

Form 10A

4(A).

Office(s) in Massachusetts or elsewhere from which the solicitation will be conducted. Attach

separate page if necessary:

Address:

City:

State:

Zip Code:

Phone:

Fax:

4(B).

Professional solicitor’s employee(s) or agent(s) who will be primarily responsible for conducting

and supervising solicitations at each office listed in Question 4(A) above. Attach separate pages if

necessary; include ALL sub-contractors.*

Name:

Title:

Address:

Phone:

Name:

Title:

Address:

Phone:

*Sub-contractors must be registered and bonded with Massachusetts before solicitation occurs. The

registrant holding the contract with the charitable organization is responsible for filing the contract and any

applicable financial report with the Division.

If any Officer, Director, Trustee, Partner, Management Employee or Owner of more than

10% of the professional solicitation entity filing this form, or a relative of any of them,

now or within the past two calendar years, has served as an Officer, Director, Trustee,

Partner, Management Employee or in any way has been affiliated with or in control of,

directly or indirectly, the charity that is the beneficiary of this campaign, please place an

“X” in the box to the right and attach an explanation in which you name the affiliated

persons and describe the affiliation.

If any Officer, Director, Trustee, Partner, Management Employee or Owner of the charity

that is named in Question 2 above, or a relative of any of them, now or within the past two

calendar years, has served as an Officer, Director, Trustee, Partner, Management

Employee or Owner of more than 10% of the professional solicitor filing this form, in any

way has been affiliated with or in control of, directly or indirectly, the professional

solicitor, please place an “X” in the box to the right and attach an explanation in which you

name the affiliated persons and describe the affiliation.

Describe the charitable purpose(s) benefiting from the solicitation. Be as specific as possible.

Form 10A

Page 2 of 6

Rev. 07/2007

Form 10a - Form Of Addendum To Registration Statement To Be Filed By Professional Solicitors Page 2