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Form Fc - Fund-Raising Counsel Application For Registration - Mississippi Secretary Of State

MISSISSIPPI SECRETARY OF STATE

FORM FC

FUND-RAISING COUNSEL

APPLICATION FOR REGISTRATION

INITIAL ________

RENEWAL ________

MISSISSIPPI REGISTRATION # F-________

Full name and mailing address:

Street address:

Telephone number:

Fax number:

Contact person name, address and phone number:

E-mail: _________________________________

Organization: Corporation___ Partnership___ Other____ (Explain)

Date and place of organization:

Federal Employer Identification #

Attach a list of corporate officers, directors, partners, and/or owners of the organization. This list must

include full name, address, and phone number.

Attach a list of other state or governmental agencies where applicant is registered.

Attach a list of all organizations which solicit contributions in Mississippi with which applicant presently

has contracts to act as Fund Raising Consultant. This list must include name, contact person, address, and

phone number.

State nature of any business other than fund-raising counsel conducted by the applicant.

A) Does applicant or any of its representatives solicit contributions from the public?

YES___ NO___

B) Does applicant or any of its representatives have access to contributions or other receipts from

solicitations?

YES___ NO___

C) Does applicant or any of its representatives have authority to pay expenses associated with a

solicitation?

YES___ NO___

Has applicant or any of its representatives ever been, or are they now, associated with any charitable or other

Form Fc - Fund-Raising Counsel Application For Registration - Mississippi Secretary Of State