Form Agtax-2 - Registration Statement For Professional Solicitor - 2012 Page 2
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29. Has a license, permit or registration of applicant ever been denied, suspended or revoked by any governmental agency, or are
such proceedings pending? Yes
No
If “Yes”, state reasons for such denial, suspension or revocation and attach copy of
such denial, suspension or revocation.
10. Has applicant, any officer or director of the applicant, any person with a controlling interest in the applicant, or any person the
applicant employs, engages or procures to solicit for compensation ever been convicted by a court of any state or the United
States of any felony, or any misdemeanor involving dishonesty or arising from the conduct of a solicitation for a charitable
organization or purpose? Yes
No
If “Yes”, give complete information.
11. Are all contracts with charitable organizations on file with the Tax Division of 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, shouldn’t re-file contracts previously filed with the Department.
Item 12 need only be completed by initial registrants
12. Date organization first solicited contributions from Hawaii residents on behalf of a charitable organization:
____________ (If not applicable, please state such).
I hereby certify, under the penalties provided in section 710-1063, 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.
Bond Form AGTAX-3 completed and signed.
Any contracts/solicitation notices not previously filed.
$250 registration fee.
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