Form Ss-6003 - Application For Registration Of A Professional Solicitor (2009) Page 2
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21. Name / Address:
Type of service:
2. Name / Address:
Type of service:
3. Name / Address:
Type of service:
4. Name / Address:
Type of service:
B. Attach a copy of the contract(s) with those listed in 5A, signed by one (1) offi cial of the charitable organization and
one (1) offi cer of the professional solicitor’s organization.
6. Are any individuals, partners, offi cers, directors, or managing agents affi liated with, controlled by, or have control over,
directly or indirectly, any nonprofi t organization listed in #5 above?
Yes
No
If yes, list the name of the individual, partner, offi cer and the controlled organization.
7. List the name(s) and address(es) of third parties (e.g., “cagers”) who will have custody and control over funds solicited
during the campaign:
8. List the other states where applicant solicits contributions:
9. 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 of the action:
B. Has anyone recovered from any of the applicant’s surety bonds? Yes
No
If “yes”, give the name, date, State, and amount recovered:
10. Have any individual owners, partners, or corporate offi cers been convicted of a felony?
Yes
No
If “yes”, list the name, criminal offense, date, and place of the conviction:
Signature
This document must be signed by an authorized offi cer. 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.
Signature
Print Name
Title
Date
SS-6003 (Rev. 4/09)
RDA 1742
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