Form Agtax-2 - Registration Statement For Professional Solicitor - 2012

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STATE OF HAWAII
Rev.1-12
DEPARTMENT OF THE ATTORNEY GENERAL
TAX DIVISION
425 QUEEN STREET
HONOLULU, HAWAII 96813
(808) 586-1480
FAX (808) 586-8116
REGISTRATION STATEMENT FOR
PROFESSIONAL SOLICITOR - FORM AGTAX-2
INITIAL
RENEWAL
FEE REMITTED ___________
(
CHECK ONE ABOVE)
1. Business name and address of applicant:
FULL BUSINESS NAME
c/o
COUNTRY
STREET AND NUMBER
CITY
STATE
ZIP CODE
COUNTY
TELEPHONE #
800 TELEPHONE #
2. Any other names under which you conduct business:
3. Form of organization:
a. Corporation
(State of Incorporation and Date) ________________________
c. Individual
b. Partnership
d. Other
4. If principal place of business is located outside Hawaii do you have any offices in Hawaii?
Yes
No
If “Yes”, attach address(s), telephone number(s) and person(s) in charge of each office.
5. Attach a list of the names and residence addresses of all principals of the organization, including officers, directors, and owners.
6. Provide the name of all persons who supervise any solicitation activity with respect to the solicitation of contributions from
Hawii residents.
7. If you answer “Yes” to any of the following, attach list of related individuals with names and relationship. Are any of the 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 the applicant? Yes
No
8. Has the organization ever voluntarily entered into any legally enforceable agreement such as an assurance of voluntary
compliance or discontinuance with any District Attorney, Office of Attorney General, local or state governmental agency?
Yes
No
If “Yes”, attach copy of such agreement.
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