Form Char 014 - Fund Raising Counsel Registration Statement (Page 2 of 2) in pdf

FUND RAISING COUNSEL REGISTRATION STATEMENT (continued)

6. DO YOU OR THE FIRM EMPLOY ANY PROFESSIONAL SOLICITORS? ...............................................................................................................

YES

7. ENTER NAME, RESIDENCE ADDRESS AND TITLE OR RELATIONSHIP TO THE BUSINESS AS FOLLOWS: FOR INDIVIDUALS, THE APPLICANT; FOR

PARTNERSHIPS, ALL PARTNERS; FOR CORPORATIONS, ALL CORPORATE OFFICERS AND DIRECTORS. ENTER FEDERAL ID NUMBERS FOR

EACH, SEPARATELY, AT BOTTOM OF PAGE.

7. NAME

RESIDENCE ADDRESS

TITLE OR RELATIONSHIP TO BUSINESS

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

"X" BOX, IF ATTACHMENTS ARE INCLUDED

8. HAS THE FIRM OR ANY REPRESENTATIVE OF THE FIRM EVER BEEN, OR ARE THEY NOW, ASSOCIATED WITH ANY CHARITABLE

OR OTHER ORGANIZATION WITH WHICH THE FIRM HAS CONTRACTED TO ACT AS A FUND RAISING COUNSEL?...........................

YES*

* IF YES, COMPLETE THE FOLLOWING:

8. NAME OF INDIVIDUAL

NAME AND ADDRESS OF ORGANIZATION

TITLE OR RELATIONSHIP TO ORGANIZATION

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

"X" BOX, IF ATTACHMENTS ARE INCLUDED

9. HAS THE FIRM OR ANY REPRESENTATIVE OF THE FIRM EVER BEEN, OR ARE THEY NOW, ASSOCIATED WITH ANY OTHER

FUND RAISING COUNSEL, PROFESSIONAL FUND RAISER OR COMMERCIAL CO-VENTURER?...............................................................

YES*

* IF YES, COMPLETE THE FOLLOWING:

9. NAME OF INDIVIDUAL

NAME AND ADDRESS OF OTHER FIRM

POSITION WITH OTHER FIRM

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

"X" BOX, IF ATTACHMENTS ARE INCLUDED

10. IS THE FIRM REGISTERED AS A FUND RAISING COUNSEL OR PROFESSIONAL FUND RAISER WITH ANY OTHER STATE OR

LOCAL GOVERNMENT?.................................................................................................................................................................... .........................

YES

11. HAS THE FIRM EVER HAD ANY LICENSE, REGISTRATION OR PERMIT DENIED, CANCELLED, SUSPENDED OR REVOKED, OR

HAS ANY OFFICIAL DISCIPLINARY OR LEGAL ACTION EVER BEEN TAKEN, OR IS ONE CURRENTLY PENDING, AGAINST THE

FIRM OR ANY REPRESENTATIVE OF THE FIRM IN RELATION TO ANY FUND RAISING ACTIVITY?........................................................

YES*

* IF YES, COMPLETE THE FOLLOWING:

11. NAME AND ADDRESS (CITY/STATE)

NATURE OF ACTION(DENIED, CANCELLED, SUSPENDED, REVOKED, ETC.);

DATE

OF GOVERNMENT AGENCY

INDICATE AGAINST WHOM ACTION WAS OR IS BEING TAKEN

(MO/DAY/YR)

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

"X" BOX, IF ATTACHMENTS ARE INCLUDED

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

AND IN ANY ACCOMPANYING PAPERS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.

Signature of Registrant

Title

Date

7. (CONTINUED) ENTER THE NAME AND FEDERAL SOCIAL SECURITY AND EMPLOYER IDENTIFICATION NUMBERS FOR EACH INDIVIDUAL NAMED IN

ITEM #7, ABOVE. FOR FURTHER INFORMATION, PLEASE REFER TO THE PRIVACY NOTIFICATION ON THE REVERSE SIDE OF THIS FORM.

EXPLANATION IF

NAME

SOCIAL SECURITY #

EMPLOYER IDENTIFICATION #