Form Sa-1 - Application For Registration As A Solicitor Agent Page 2
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26.
In the past ten years has the applicant been convicted of or pled guilty or nolo contendere (no contest) to a felony or misdemeanor
which:
(A) Involves the solicitation or acceptance of charitable contributions or the making of a false oath, the making of a false report, bribery,
perjury, burglary, or conspiracy to commit any of the foregoing offenses?
□
□
Yes
No
(B) Arises out of the conduct of solicitation of contributions for a charitable organization?
□
□
Yes
No
(C) Involves the larceny, theft, robbery, extortion, forgery, counterfeiting, fraudulent concealment, embezzlement fraudulent conversion, or
misappropriation of funds?
□
□
Yes
No
(D) Involves murder or rape?
□
□
Yes
No
(E) Involves assault or battery if such person proposes to be engaged in counseling, advising, housing, or sheltering of individuals?
□
□
Yes
No
(F) Pled guilty or nolo contendere (no contest) to any other felony offense?
□
□
Yes
No
7.
Has any registration in any state ever been denied, revoked, suspended, or withdrawn?
□
□
Yes
No
8.
Has Applicant ever been subject to any injunction or disciplinary proceeding by any state agency involving any aspect of fund raising
or solicitation?
□
□
Yes
No
9.
Has Applicant ever been subject to an order, consent order or any other disciplinary or administrative proceeding pursuant to the unfair
and deceptive acts and practices law of any state?
□
□
Yes
No
If the answer is “yes” to any of the aforementioned questions or if such proceeding is pending in any state, attach all pertinent information with
respect to such injunction, disciplinary proceeding, conviction or charges.
If the applicant is seeking to be qualified to contact contributors and potential contributors in person, the applicant, by signing this
application, gives the Office of the Secretary of State authorizes to conduct a criminal history background investigation.
10.
Will applicant solicit contributions in person, as distinguished from mail, telephonic or electronic contact?
□
□
Yes
No
If the answer is “yes”, provide:
Social Security Number: __________________________________
Date of Birth: ____________________________________
SOLICITOR AGENT CERTIFICATION
The undersigned applicant represents that the information and statements contained in this application, including the attached exhibits,
are current, true and complete. The undersigned further represents that to the extent any information previously submitted is not amended, such
information is currently accurate and complete. By signing this certification, the applicant certifies that he/she is at least 18 years of age and that
willful misstatements or omissions of fact may result in administrative, civil or criminal action.
_________________________________________________________________
Print Name of Applicant
_________________________________________________________________
____________________________
Signature of Applicant
Date
Sworn to and subscribed before me this _________
Day of _________________________, 20_________
Notary Public ____________________________________________My Commission Expires: _______________________________
Form SA-1 Rev. Jan 2010
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