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WARNING: False or misleading statements subject to
State of Tennessee
maximum $5,000 penalty. T.C.A. §48-101-514
Department of State
APPLICATION FOR REGISTRATION
Division of Charitable Solicitations & Gaming
OF A PROFESSIONAL SOLICITOR
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
OFFICE USE ONLY
INSTRUCTIONS: Type or print your answers. If an answer does not apply, write
Reg. No.
Date Received
“N/A.” Attach additional sheets if you are unable to answer in the space provided. A
Fee Pd.
nonrefundable registration fee of $800.00 and a $25,000 bond, payable to the State
Rec. No.
of Tennessee, must accompany this application.
1. A. Name of organization:
B. List other names currently or previously used to conduct business:
C. Federal Employer Identifi cation Number:
2. A. Principal Address:
(Street)
(City)
(State)
(Zip)
B. Mailing Address:
(Street)
(City)
(State)
(Zip)
C. List address of additional offi ces / places of operation in Tennessee.
D. Contact Name / Address:
(Name)
(Street)
(City/State)
(Zip)
(phone)
(fax)
(email)
3. A. Applicant is and Individual
Partnership
Corporation
Other
B. Year organized
State
4.
List corporate offi cers and directors of corporation or unincorporated association; each partner in the
partnership; or owner in sole proprietorship.
Name
Title
Address
Phone
1.
2.
3.
5. A. List all current contracts to solicit contributions from or within Tennessee between the professional solicitor and
charitable organizations. Describe the type of service provided. (e.g., telemarketing, direct mail, Internet, etc.)