Charitable Organization Application Part 1
1. Organization’s name: _________________________________________________________________
2. Name or names under which organization intends to solicit contributions:
_____________________________________________________________________________________
_____________________________________________________________________________________
3. EIN: ______________________________________________________________________________
4. Principal address and phone number(s):
_____________________________________________________________________________________
_____________________________________________________________________________________
3. Contact Information (Name, address, e-mail and phone number):
_____________________________________________________________________________________
_____________________________________________________________________________________
4. If the charitable organization does not maintain an office, provide the name and address of person with
custody of financial records:
_____________________________________________________________________________________
_____________________________________________________________________________________
5. List all other states where the organization is licensed/registered:
_____________________________________________________________________________________
_____________________________________________________________________________________
6. (a) State the percentage of contributions received in the immediately preceding year that was spent for
fund raising and administration: ___________________________________________________________
(b) If exact percentage is unavailable, please provide estimate: ________________________________
7. Where applicable, please attach the following documents:
IRS Form 990, Audited Financial Statement, or Compiled Financial Statements
List of the addresses of the Organization and the addresses of any offices in this state.
A list of name(s) and address(es) of all professional fund raisers and fundraising counsel who are
acting or have agreed to act in this state on behalf of the organization.
A copy of the contract(s) for the professional fund raiser and fundraising counsel services.