Form Char 012 - Professional Solicitor - Registration Statement Form

CHAR 012

FOR OFFICE USE ONLY

STATE of NEW YORK

DATE REC'D.

AMOUNT

Professional Solicitor

DEPARTMENT OF LAW

CHARITIES BUREAU

Registration Statement

CASH BK.#

REG. NO.

THE CAPITOL

ALBANY, NY 12224

DATE ACCT.

EXAMINED BY

FOR YEAR ENDING AUGUST 31, 20

INSTRUCTIONS: Please type or print in ink the answers to all applicable items on both sides of this form. (Enter "NA" for any item that is not

applicab le.) This fully execu ted statemen t, along with the m andatory fee of $80 (Art. 7-A, Exec. Law), in the form of a check or money order made

payable to the "Department of Law", should be sent to the above address. Please be sure to sign this statement where indicated and include all

attachments, clearly labeled to reference any item requiring additional explanation.

NOTE: The Ch arities Burea u must be no tified in writing within 20 days, if any changes to the information provided in this statement occur during

the period of registration (Art. 7-A, Exec. Law).

1. FULL NAME OF PROFESSIONAL SOLICITOR

PRIOR NYS REGISTRATION # (IF ANY)

...........................................................................................................................................................................................

.....................................................................

HOME ADDRESS-NUMB ER AND STREET

CITY, STATE, ZIP

HOME TELEPHONE NUMBER

(

)

2. LIST ANY OTHER NAME(S) YOU ARE KNOWN OR HAVE BEEN KNOWN BY OR USED

3. WORK ADDRESS--NUMBER AND STREET (ROOM NUMBER)

CITY, STATE, ZIP

TELEPHONE NUMBER

(

)

4. ENTER ALL PAST AND PRESENT EMPLOYMENT AS A PROFESSIONAL SOLICITOR, PROFESSIONAL FUND RAISER (PFR), FUND RAISING COUNSEL, OR

COMMERCIAL CO-VENTURER. LIST PRESENT EMPLOYMENT FIRST, AND INCLUDE ALL TERMS OF REMUNERATION AGREED UPON WITH PFRs.

4.

NAME OF EMPLOYING FIRM

TERMS OF REMUNERATION

PERIOD

(Not a Charitable Organization Name)

COMPLET E ADDRESS AND TELEPHONE NUMBER

(Salary in $ or % Commission)

(Month/Year)

.........................................................................................

FROM:

............................... ....................... ....................... ............

TO:

..........................................................................................

FROM:

.............................. ....................... ....................... ..............

TO:

..........................................................................................

FROM:

.............................. ....................... ....................... ..............

TO:

"X" BOX, IF ATTACHMENTS ARE INCLUDED

5. ARE YOU AUTHORIZED BY ANY OTHER STATE OR LOCAL AGENCY TO SOLICIT CONTRIBUTIONS FOR CHARITABLE OR

OTHER ORGANIZATIONS?..........................................................................................................................................................................................

YES

NO

6. HAS ANY AUTH ORITY TO SOLICIT CON TRIBUTIONS BE EN DENIED, C ANCELLED, SUS PENDED OR REVOKED, OR HAS ANY DISC IPLINARY OR LEGAL

ACTION IN RELATION TO ANY FUND RAISING ACTIVITY EVER BEEN TAKEN AGAINST YOU OR IS ANY ACTION PENDING?...........

YES*

NO

* IF YES, COMPLETE THE FOLLOWING:

6. NAME AND ADDRESS (CITY/STATE)

DATE

OF GOVERNMENT AGENCY

NATURE AND OUTCOME (DENIED, CANCELLED, SUSPENDED, REVOKED, ETC.)

(MO/DAY/YR)

....................................................................................................................................................................................................................................................................................

"X" BOX, IF ATTACHMENTS ARE INCLUDED

7. SEE REVERSE SIDE FOR ITEM 7-MANDATORY REPORTING OF SOCIAL SECURITY AND EMPLOYER IDENTIFICATION NUMBERS. (NOT

AVAILABLE TO THE PUBLIC)

I, THE REGISTRANT, CERTIFY UNDER THE PENALTY OF PERJURY, THAT THE STATEMENTS MADE IN THIS DOCUMENT

AND IN ANY ACCOM PANYING PAPERS ARE TRUE TO TH E BEST OF MY KNOWLED GE AND BELIEF.

X

Signatu re of Reg istrant

Title

Date

PURSUANT TO EXECUTIVE LAW, NONCOMPLIANCE WITH REGISTRATION REQUIREMENTS IS A MISDEMEANOR IN NEW YORK STATE.

EXCEPT FOR THE INFORMA TION PROVIDED ON THE REVERSE SIDE, THIS FORM, INCL UDING ANY ATTACHMENTS, IS A PUBLIC RECORD AND A

COPY SHALL BE PROVIDED, UPON REQUEST, TO ANY INTERESTED PERSON.