Application For Professional Solicitor/mandatory Addendum Form To License Application
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1
2State of Rhode Island and Providence Plantations
DEPARTMENT OF BUSINESS REGULATION
SECURITIES DIVISION
CHARITABLE ORGANIZATION SECTION
1511 Pontiac Avenue, Bldg. 69-1
Cranston, Rhode Island 02920
FILINGS MUST BE SUBMITTED ON CD-ROM. WE NO LONGER
ACCEPT PAPER FILINGS
E-LICENSING NOW AVAILABLE. APPLY ONLINE AT
https://elicensing.ri.gov
**You can check the status of your application by logging into
https://elicensing.ri.gov
with your Personal User ID and Password.
(If you do not have your Personal User ID and Password, please contact the Division at 401-462-9527.)
APPLICATION FOR PROFESSIONAL SOLICITOR
____
INITIAL APPLICATION
TH
ANNUAL EXPIRATION: JUNE 30
____ RENEWAL APPLICATION
1. NAME: ____________________________________________________
2. DATE OF BIRTH: ___________________________________________
3. SOCIAL SECURITY NUMBER: _______________________________
4. ADDRESS: ____________________________________________________________________________________
ZIPCODE
STREET
CITY
STATE
5. NAME, ADDRESS, E-MAIL ADDRESS, AND PHONE NUMBER OF EMPLOYING FUNDRAISER:
6. CONTACT SUPERVISOR AND MAILING ADDRESS:
7. HAS ANY LICENSE OR REGISTRATION BEEN DENIED, CANCELLED OR REVOKED, OR HAS ANY ACTION BEEN
TAKEN AGAINST YOU IN CONNECTION WITH SOLICITATION OF FUNDS
FOR CHARITABLE PURPOSES? ____ YES _____ NO
8. HAVE YOU EVER BEEN CONVICTED OF A CRIME INVOLVING THE MISUSE OR THEFT OF MONEY? ___YES ___ NO
9. HAVE YOU EVER BEEN CONVICTED OF A CRIME OF DISHONESTY, THEFT, BURGLARY, DECEPTION, OR
FRAUD? ____YES ____NO
10.SUBMISSION OF TAX PAYER STATUS AFFIDAVIT (ATTACHED TO APPLICATION AS EXHIBIT 1)
I CERTIFY UNDER PENALTY OF PERJURY THAT I HAVE READ THIS APPLICATION AND KNOW THAT ALL
STATEMENTS THEREIN ARE TRUE.
_______________________________
___________________________________
(Signature)
(Date)
____________________________________
(Print Name)
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