Form Agtax-1 - Registration Statement For Professional Fundraising Counsel - 2012 Page 2
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28. If you answer “Yes” to any of the following, attach a list of related individuals with names and relationship. Are any owners,
directors, officers or employees of the applicant related by blood, marriage or adoption to:
(A) Any other directors, officers, owners or employees of the applicant? Yes
No
(B) Any officer, director, trustee or employee of any charitable organization under contract with applicant? Yes
No
(C) Any supplier or vendor providing goods or services directly or indirectly to any charitable organization under
contract with applicant? Yes
No
9. Are all contracts with charitable organizations soliciting contributions from Hawaii residents on file with the Hawaii
Department of the Attorney General? Yes
No
Not Applicable
If “No”, attach copies. File only those contracts
regarding the solicitation of contributions from Hawaii residents. Renewal registrants, should not re-file contracts previously
filed with the Department of the Attorney General.
Item 10 need only be completed by initial registrants
10. Date organization first acted as a professional fundraising counsel with respect to a charitable organization’s solicitation of
contributions from Hawaii residents: ____/____/____ (If not applicable, please state such).
I swear or affirm, under the penalties provdied in section 710-1062, Hawaii Revised Statutes, that the
information provided in this registration is true and correct.
DATE
SIGNATURE OF PRINCIPAL OFFICER
TYPE OR PRINT NAME AND TITLE OF
PRINCIPAL OFFICER
CHECKLIST
Registration Statement signed.
Any attachments to the Registration Statement.
Any contracts/solicitation notices not previously filed.
$250 registration fee.
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