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Form C100 - Georgia Charitable Solicitations Act Charitable Organization Registration Page 5

APPLICANT’S NAME:

CONTROL PERSONS

The applicant must provide the following information for each person who directly or indirectly,

has the power to direct or cause the direction of the management and policies of the applicant.

The term control person includes, but is not limited to,

each executive officer or person holding similar position.

Make additional copies of this form as needed.

(Please type or print)

Name:

Title:

Address:

City:

State:

Zip Code:

Date of Birth:

Social Security Number:

ten year employment history

The person named above MUST provide a

beginning with the most recent employment.

Attach separate sheets if needed.

All persons who have custody of charitable donations must submit to a criminal background check. By

signing this form, the person named above authorizes the Secretary of State to conduct a criminal history

check pursuant to the charitable organization’s registration in the State of Georgia.

Signature of Control Person

This

Day of

Official Witness (Notary)

Signature

Form C100 Rev. Sept 2010

Page 5

Form C100 - Georgia Charitable Solicitations Act Charitable Organization Registration Page 5