Form C100 - Georgia Charitable Solicitations Act Charitable Organization Registration

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Professional Licensing Boards and Securities Division
237 Coliseum Drive
Macon, GA 31217-3858
(478) 207-2440
Tanja Battle
Brian P. Kemp
Georgia Charitable Solicitations Act
Secretary of State
Executive Director
Charitable Organization Registration
EXECUTION PAGE
Statutory Fees
(Nonrefundable)
Make Check Payable to Georgia Secretary of State
INITIAL
REINSTATEMENT
APPLICATION
AMENDMENT
Registration #: _____________
$35.00
(No Fee Required)
$35.00
WARNING: Failure to keep this form current and file accurate supplemental information on a timely basis, or
failure to keep accurate books and records or otherwise comply with provisions of the Georgia
Charitable Solicitations Act of 1988, is a violation of said Act and may result in disciplinary,
administrative, injunctive or criminal action. INTENTIONAL MISSTATEMENTS OR OMISSIONS OF
FACT MAY CONSTITUTE CRIMINAL VIOLATIONS.
1. Official Name and Mailing Address of Applicant (Charitable Organization):
2. Other Names under which solicitations will be made:
3. Contact Person:
Telephone:
Contact Person Email Address for Official Correspondence:
4. Location of Books and Records:
EXECUTION: On behalf of the applicant identified above, for the purpose of complying with the Charitable Solicitations Act of 1988, as amended
(O. C. G. A. 43-17-1 et seq.) (“Act”), I hereby certify that the applicant is in compliance with said Act and irrevocably appoints the Secretary of State
of the State of Georgia the agent for the applicant upon whom may be served any notice, process or pleading in any action or proceeding against
the applicant arising out of, or founded upon, a violation or an alleged violation of said Act. The applicant hereby consents that any such action or
proceeding against said applicant may be commenced in any court of competent jurisdiction and proper venue within the State of Georgia by
service of process upon Secretary of State with the same effect as if the applicant was a resident of the State of Georgia and had been personally
served with process. The undersigned hereby verifies that he had executed this form on behalf of, and with the authority of, said applicant. The
undersigned and applicant represent that the information and statements contained herein, including the exhibits attached hereto, and other
information filed herewith, all of which are made a part hereof, are current, true and complete. The undersigned and applicant further represent that
to the extent any information previously submitted is not amended, such information is currently accurate and complete.
Name of authorized Executive Officer (please type or print):
Date:
Signature of Executive Officer:
Title:
Official Witness (Notary)
THIS PAGE MUST ALWAYS BE COMPLETED IN FULL with original manual signature and notarization
with seal. To amend, circle number(s) being amended. To explain answers attach additional sheets
identifying the questions and provide explanation.
Form C100 Rev. Sept 2010
Page 1

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