Form Sa-1 - Application For Registration As A Solicitor Agent - State Of Georgia
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5Professional Licensing Boards and Securities Division
237 Coliseum Drive
Macon, GA 31217-3858
(478) 207-2440
Brian P. Kemp
Secretary of State
Application for Registration as a Solicitor Agent
Pursuant to The Georgia Charitable Solicitation Act of 1988, As Amended
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Initial Registration - $ 50.00
Amendment - $15.00
Reinstatement - $50.00
INSTRUCTIONS: THIS APPLICATION MUST BE COMPLETED AND FILED BEFORE SOLICITING CHARITABLE CONTRIBUTIONS. ALL AGENT
REGISTRATIONS EXPIRE ON DECEMBER 31. ANSWER ALL QUESTIONS COMPLETELY, ATTACHING ADDITIONAL PAGES IF MORE SPACE IS
NEEDED. CHECKS SHOULD BE MADE PAYABLE TO THE SECRETARY OF STATE. AMENDMENTS TO THIS REGISTRATION SHOULD BE FILED
PROMPTLY, USING THIS FORM, TO REFLECT ANY CHANGES IN THE INFORMATION SUBMITTED.
1.
(a) Full Name of Applicant: _____________________________________________________________________________________
(b) Home Address: ____________________________________________________________________________________________
(Address)
____________________________________________________________________________________________________________
(City)
(State)
(Zip)
(Telephone No.)
2.
Address of Each Place of Business: _______________________________________________________________________________
(Address)
____________________________________________________________________________________________________________
(City)
(State)
(Zip)
(Telephone No.)
3.
Identify the name(s) and address(s) of Paid Solicitor or Fundraising Counsel with which Agent will be affiliated. Indicate if affiliation
is as an employee or as an independent contractor. Attach additional pages as needed.
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Employee
Independent Contractor
____________________________________________________________________________________________________________
Name of Paid Solicitor/Fundraising Counsel
SOS Registration No.
____________________________________________________________________________________________________________
(Address)
____________________________________________________________________________________________________________
(City)
(State)
(Zip)
____________________________________________________________________________________________________________
Contact Person
Telephone No.
4.
If Applicant is an independent contractor, attach a copy of contract(s) indicated on #3.
5.
Attach a list of all other sates in which Applicant is registered.
Form SA-1 Revised Aug 2012
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