Form Ss-6040 - Application For Registration Of A Professional Fundraising Counsel (Page 2 of 2) in pdf

Form Ss-6040 - Application For Registration Of A Professional Fundraising Counsel Page 2

6. List other states where applicant is registered:

7. A. Has the applicant: (1) had any license, registration, or permit revoked or denied or (2) been enjoined or

prohibited from soliciting contributions? If “yes”, describe the action, date, and place:

8. Disclose any civil administrative or other legal action filed against applicant pursuant to any State or local

charitable solicitations act, including the complete case style, summary, and disposition of the action:

Signature

This document must be signed by an authorized officer. I certify that the statements in this registration statement and all

supplemental forms, documents, and continuation sheets are true and correct to the best of my knowledge and belief.

First:

Last:

MI:

Title:

Date:

Signature:

SS-6040 (Rev. 4/11)

RDA 1742

Form Ss-6040 - Application For Registration Of A Professional Fundraising Counsel Page 2