Form Cri-500s - Solicitor Of An Independent Paid Fund Raiser - Initial Registration And Renewal Registration Page 2

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5. List all other employment experience in the past five (5) years.
Name and Address of Employer
Nature of Employment
Period (month/year)
6. Are you licensed by, registered with, or have a permit from any other state governmental agency to solicit funds for
£ Yes £ No
charitable organizations? Choose and check one:
If the response to this question is “Yes,” please provide (on a separate sheet of paper) the following information: the
name of each state and government entity which issued the license, permit or registration, the type of license, permit
or registration, along with the designated identification number, and the date of authorization in each state (format
month/day/year).
7.
Has any license, registration or permit ever been denied, suspended, canceled or revoked, or has any disciplinary action been
taken against you, or have you been named as a party to a legal action brought in connection with any misconduct involving
£ Yes £ No
charitable solicitation activity? Choose and check one:
If the response to this question is “Yes,” please provide (on a separate sheet of paper) the following information:
the name of each state and the name and address of the governmental agency which took action; the allegations made
against you in the action(s); the disposition of the action and the date of disposition (format month/day/year). Provide
photocopies of any and all written documentations (such as a court order, administrative order, judgment, formal notice or
written assurance) which support your affirmative response.
8. Have you ever been adjudged liable in an administrative or civil action or convicted in a criminal action involving theft,
£ Yes £ No
fraud or deceptive practices? Choose and check one:
If the response to this question is “Yes,” please provide (on a separate sheet of paper) the following information:
the name of the individual or agency that brought the action against you; the allegations made against you in
the action; the court or agency in which the action was brought; the disposition of the action and the date of
disposition (month/day/year).
NOTE: For purposes of this question, a plea of guilty, non vult, nolo contendere or any similar disposition of
alleged criminal activity shall be deemed a conviction. Provide photocopies of any and all written documentation
(such as a court order, administrative order, judgment, formal notice or written assurance) which support your affirmative
response.
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