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Form 10 - Registration Statement To Be Filed By Professional Solicitors, Professional Fund-Raising Counsel, And Commercial Co-Venturers Page 3

Form 10

If the registrant is licensed by, registered with, or has a permit from any governmental agency

outside of Massachusetts as a professional solicitor, professional fund-raising counsel, or

commercial co-venturer, please complete the following information. (Attach a separate sheet if

necessary.)

Authorization date

Name of Agency

City/State

(MM/DD/YYYY)

If any license or permit has been denied, cancelled, revoked, or suspended, or if any legal or

administrative action has been taken against you in connection with solicitation of funds for

charitable purposes, please complete the following information. (Attach a separate sheet if

necessary.)

Authorization date

Action Taken By

Type of Action

(MM/DD/YYYY)

If you or any of your employees or agents has ever been convicted of a misdemeanor involving

the misappropriation, misapplication, or misuse of money of another, or of any felony, please

complete the following information. (Attach a separate sheet if necessary.)

Authorization date

Action Taken By

Type of Action

(MM/DD/YYYY)

PROFESSIONAL SOLICITORS ONLY: If the registrant has worked for another professional

solicitor, he or she must list ALL solicitation-related employment from the last five years on

another sheet. Include the name, address, and phone number of the employer, the nature of

the employment, and the length of employment.

CERTIFICATION BY THE REGISTRANT:

Under the pains and penalties of perjury, I certify the above declaration to be true and correct to the best

of my knowledge.

Signature on behalf of Registrant

PRINT name and title

Date signed

PROFESSIONAL SOLICITORS: Submit this form with the Form 9 surety bond and $300 filing fee.

PROFESSIONAL FUND-RAISING COUNSEL: Submit this form with a $200 filing fee.

COMMERCIAL CO-VENTURERS: Submit this form with the Form 9 surety bond and $50 filing fee.

**Fees are payable by check or money order and should be made out to the Commonwealth of Massachusetts.**

OFFICE USE ONLY

Payment received:

Form 10

Page 3 of 3

Rev. 07/2007

Form 10 - Registration Statement To Be Filed By Professional Solicitors, Professional Fund-Raising Counsel, And Commercial Co-Venturers Page 3