Form Char012 - Professional Solicitor Registration Statement - Department Of Law
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1
2CHAR012
FOR OFFICE USE ONLY
STATE OF NEW YORK
DATE REC'D.
FEE REC'D
Professional Solicitor
DEPARTMENT OF LAW
CASH BK.#
I.D. #
CHARITIES BUREAU
Registration Statement
THE CAPITOL
(Article 7-A of the
START DATE
END DATE
ALBA NY, NY 12224
Executive Law)
www .oag.state.ny.us/charities/charities.html
ACCPT. DATE
REVIEWER
INSTRUCT IONS: Please type or print in ink the answ ers to all applicable items on both sides of this form. (Enter "NA" for any item that is not
app licable.) In all cases, "the Registrant" shall mean the Professional Solicitor named in Item 1. This fully executed statement, along with the
mandatory fee of $80, in the form of a check or money order mad e payable to the "Department of Law", should be sent to the above address.
Please be sure to sign this statement where indicated and include all attachments, clearly labeled to reference any item requiring additional
explanation. NOTE: A Professional Solicitor's registration expires one year from the date of registration or re-registra tion. T he Registrant shall
notify the Charities Bureau in writing, certified und er penalties for perju ry, within 20 days o f any material cha nge to the inform ation p rovid ed in
this statement.
1. FULL LEGAL NAME OF PROFESSIONAL SOLICITOR (Name must be used when acting as a Professional Solicitor)
PREVIOUS NYS I.D. # (if any)
HOME ADDRESS-NUMBER AND STREET
CITY, STATE, ZIP
E-MAIL ADDRESS
HOME TELEPHONE NUMBER
(
)
2. WORK ADDRESS--NUMBER AND STREET (ROOM NUMBER)
CITY, STATE, ZIP
TELEPHONE NUMBER
(
)
3. ENTER ALL PAST AND PRESENT EMPLOYMENT AS A PROFESSIONAL SOLICITOR (PS), PROFESSIONAL FUND RAISER (PFR) OR FUND RAISING
COUNSEL (FRC). LIST PRESENT EMPLOYMENT AS A PS FIRST AND INCLUDE APPROPRIATE DATES OF SOLICITATION/EMPLOYMENT.
NAME, ADDRESS & TELEPHONE #
OF EMPLOYING PFR/FRC
DATES OF SOLICITATION/EMPLOYMENT
D
R
B
/S
B
NYS
I
,
ATE
EGISTRANT
EGAN
HALL
EGIN
N THIS SECTION
ENTER INFORMATION ON
S
R
T
R
OLICITATION
ELATED TO
HIS
EGISTRATION
CURRE NT PS EM PLOYM ENT SPEC IFICALLY A S IT
S
:
UBMISSION
RELATES TO THIS REGISTRATION SUBMISSION
B
D
:
EGINNING
ATE
(MM/DD/YYYY)
I
,
,
N THIS SECTION
AND ANY ATTACHMENTS
ENTER
B
D
EGINNING
ATE
,
INFORMATION ON ALL PR EVIOUS PS
PFR AND FRC
E
(MM/DD/YYYY)
OF
MPLOYMENT
EMPLOYMENT NOT RELATED TO THIS SUBMISSION
E
D
ND
ATE
E
(MM/DD/YYYY)
OF
MPLOYMENT
"X" BOX, IF ATTACHMENTS ARE INCLUDED
4. IS THE REGISTRANT AUTHORIZED BY ANY OTHER STATE OR LOCAL AGENCY TO SOLICIT CONTRIBUTIONS FOR CHARITABLE
OR OTHER ORGANIZATIONS?..........................................................................................................................................................................................
YES
NO
5. A. HAS THE REGISTRANT EVER HAD ANY LICENSE, REGISTRATION OR PERMIT DENIED, CANCELED, SUSPENDED OR REVOKED,
OR HAS ANY OFFICIAL DISCIPLINARY OR LEGAL ACTION EVER BEEN TAKEN, OR IS ONE CURRENTLY PENDING, AGAINST
G
G
THE REGISTRANT IN CONNECTION WITH ANY FUND RAISING ACTIVITY?.................................................................................................
YES*
NO
B. HAS THE REGISTRANT EVER ENTERED INTO ANY AGREEMENT WITH ANY REGULATORY BODY REGARDING THE
G
G
REGISTRANT'S CONDUCT IN CONNECTION WITH ANY FUND RAISING ACTIVITY?..................................................................................
YES*
NO
C. HAS THE REGISTRANT EVER BEEN CONVICTED OF A FELONY OR OF A MISDEMEANOR INVOLVING THE MISAPPROPRIATION
OR MISUSE OF THE MONEY OR PROPERTY OF ANOTHER AND HAS NOT, SUBSEQUENT TO SUCH CONVICTION, RECEIVED
G
G
EXECUTIVE PARDON OR A CERTIFICATE OF GOOD CONDUCT FROM THE PAROLE BOARD?...............................................................
YES*
NO
* IF YES, COMPLETE THE FOLLOWING:
NAME AND ADDRESS (CITY/STATE)
DATE
OF GOVERNMENT AGENCY
NATURE AND OUTCOME (DENIED, CANCELLED, SUSPENDED, REVOKED, ETC.)
(MO/DAY/YR)
"X" BOX, IF ATTACHMENTS ARE INCLUDED
6. SEE REVERSE SIDE FOR ITEM 7-MANDATORY REPORTING OF SOCIAL SECURITY AND EMPLOYER IDENTIFICATION NUMBERS. (NOT
AVAILABLE TO THE PUBLIC)
I, THE REGISTRANT, CERTIFY UNDER THE PENALTIES FOR PERJURY, THAT THE STATEMENTS MADE IN THIS DOCUMENT AND IN ANY
ACCOMPANYING PAPERS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
X
Sign ature of Re gistran t
Title of R egistra nt
Date
PURSUANT TO EXECUTIVE LAW, NONCOMPLIANCE WITH REGISTRATION REQUIREMENTS IS A MISDEMEANOR IN NEW YORK STATE.
EXCEPT FOR THE INFORMATION PROVIDED ON THE REVERSE SIDE, THIS FORM, INCLUDING ANY ATTACHMENTS, IS A PUBLIC RECORD AND A
COPY SHALL BE PROVIDED, UPON REQUEST, TO ANY INTERESTED PERSON.
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