Form Char012 - Professional Solicitor Registration Statement - Department Of Law (Page 2 of 2) in pdf

Form Char012 - Professional Solicitor Registration Statement - Department Of Law Page 2

PROFESSIONAL SOLICITOR REGISTRATION STATEMENT (continued)

6. (CONTINUED FROM FRONT) ENTER THE REGISTRANT'S LEGAL NAME AS SHOWN IN ITEM 1 (OVER) AND ENTER THE REGISTRANT'S FEDERAL SOCIAL

SECURITY NUMBER AND EMPLOYER IDENTIFICATION NUMBER (IF ANY). PLEASE NOTE THAT A WRITTEN EXPLANATION IS REQUIRED WHERE NO

NUMBER IS PROVIDED. FOR FURTHER INFORMATION, PLEASE REFER TO THE PRIVACY NOTIFICATION BELOW.

REGISTRANT'S LEGAL NAME AS SHOWN IN ITEM 1 (OVER)

SOCIAL SECURITY NUMBER

EMPLOYER IDENTIFICATION NUMBER

EXPLANATION REQUIRED, FOR ANY NUMBER NOT PROVIDED

CHAR012 (Rev. 6/03)

PRIVACY NOTIFICATION

THE CHARITIES BUREAU OF THE DEPARTMENT OF LAW IS REQUIRED TO COLLECT THE FEDERAL SOCIAL SECURITY AND EMPLOYER

IDENTIFICATION NUMBERS OF ALL REGISTRANTS. THE AUTHORITY TO REQUEST AND MAINTAIN SUCH PERSONAL INFORMATION IS FOUND IN §5

OF THE TAX LAW. DISCLOSURE BY YOU IS MANDATORY. THE INFORMATION IS COLLECTED TO ENABLE THE DEPARTMENT OF TAXATION AND

FINANCE TO IDENTIFY INDIVIDUALS, BUSINESSES AND OTHERS WHO HAVE BEEN DELINQUENT IN FILING TAX RETURNS OR MAY HAVE

UNDERSTATED THEIR TAX LIABILITIES AND TO GENERALLY IDENTIFY PERSONS AFFECTED BY THE TAXES ADMINISTERED BY THE COMMISSIONER

OF TAXATION AND FINANCE. IT WILL BE USED FOR TAX ADMINISTRATION PURPOSES AND ANY OTHER PURPOSE AUTHORIZED BY THE TAX LAW,

BUT WILL NOT BE AVAILABLE TO THE PUBLIC. A WRITTEN EXPLANATION IS REQUIRED WHERE NO NUMBERS ARE PROVIDED. THIS INFORMATION

WILL BE MAINTAINED IN THE CHARITIES INFORMATION SYSTEM BY THE CHARITIES BUREAU AT THE FOLLOWING ADDRESS:

STATE OF NEW YORK, DEPARTMENT OF LAW, CHARITIES BUREAU, THE CAPITOL, ALBANY, NY 12224

Form Char012 - Professional Solicitor Registration Statement - Department Of Law Page 2