Form Ss-6040 - Application For Registration Of A Professional Fundraising Counsel printable pdf download

Form Ss-6040 - Application For Registration Of A Professional Fundraising Counsel

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WARNING: False or misleading statements subject to

State of Tennessee

maximum $5,000 penalty. T.C.A. §48-101-514

APPLICATION FOR REGISTRATION OF A

Department of State

PROFESSIONAL FUNDRAISING COUNSEL

Division of Charitable Solicitations & Gaming

William R. Snodgrass Tennessee Tower

312 Rosa L. Parks Avenue, 8th Floor

ALL REGISTRATIONS EXPIRE DECEMBER 31

Nashville, TN 37243

(615) 741-2555 / (615) 253-5173 fax

For Office Use Only

INSTRUCTIONS: Type or print your answers. If an answer does not apply, write

Received

Reg. No.

“N/A.” Attach additional sheets if you are unable to answer in the space provided. A

nonrefundable registration fee of $250.00 payable to the State of Tennessee, must

Fee Pd.

accompany this application.

Rec. No.

1. A. Name of organization:

B. List other names the organization uses to conduct business and, if applicable, attach documents

authorizing such use:

C. Federal Employer Identification Number:

D. Contact Name:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Email:

2. A. Principal Address:

City:

State:

Zip Code:

B. Mailing Address:

City:

State:

Zip Code:

C. List address of additional offices / places of operation in the Tennessee:

Street:

City:

State:

Zip Code:

Street:

City:

State:

Zip Code:

3. A. Applicant is a Sole Proprietor

Partnership

Corporation

Other

B. Year organized

State

4. List corporate officers and directors of corporation or unincorporated association; each partner in the partnership; or

owner in sole proprietorship.

Name:

Title:

Address:

Phone:

Name:

Title:

Address:

Phone:

Name:

Title:

Address:

Phone:

5. Attach a list containing the name and address of each charitable organization soliciting from or within Tennessee,

for which the applicant is providing fundraising counsel services.

Form Ss-6040 - Application For Registration Of A Professional Fundraising Counsel

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