Form Char 013 - Professional Fund Raiser Registration Statement

CHAR 013

FOR OFFICE USE ONLY

STATE of NEW YORK

DATE REC'D.

AMOUNT

Professional Fund Raiser

DEPARTMENT OF LAW

CHARITIES BUREAU

Registration Statement

CASH BK.#

REG. NO.

THE CAPITOL

ALBANY, NY 12224

DATE ACCT.

EXAMINED BY

FOR YEAR ENDING AUGUST 31, 20

INSTRUCTIONS: Please type or print in ink the answers to all applicable items on both sides of this form. (Enter "NA" for any item that is not

applicab le.) In all cases, "the Registrant" shall mean the applicant Professional Fund Raiser named in Item 1A; "Representative of the Firm" shall

mean an owner, principal, partner, director or officer of the R egistrant. This fully executed sta tement, along with the mand atory fee of $800 (Art.

7-A, Exec. Law), in the form of a check or money order made payable to the "Department of Law", should be sent to the above address alo ng with

a $10,000 Surety Bond. The bo nd should name the registrant as the principal obligor (form enclosed). Please be sure to sign this statement where

indicated and include all attachments, clearly labeled to reference any item requiring additional explanation.

NOTE: The Charities Bureau must be notified in writing within 20 days, if any chang es to the inform ation prov ided in this statement occur during

the period of reg istration (Art. 7-A , Exec. Law ).

1A. FULL, OFFICIAL NAME OF PROFESSIONAL FUND RAISER*

TELEPHONE NUMBER

..................................................................................................................................................................................................

(

).......................................................

PRINCIP AL STRE ET ADDRESS

CITY, STATE, ZIP

...............................................................................................................................................................................................................................................................................

* ITEM #1B ON THE BACKSIDE (BOTTOM) OF THIS FORM MUST BE COMPLETED

2. ENTE R THE PR INCIPAL NEW Y ORK STATE ADDRES S/TELEP HONE NU MBER (IF NOT THE SAME AS # 1A ABOVE ) AND ALL

ADDRESSES/TELEPHONE NUMBERS FROM WHICH THE REGISTRANT AND ITS REPRESENTATIVES SOLICIT PERSONS IN NEW YORK STATE.

2. STREET ADDRESS

CITY, STATE, ZIP CODE

TELEPHONE NUMBER

"X" BOX, IF ATTACHMENTS ARE INCLUDED

3. LIST ALL OTHER LEGALLY AUTHORIZED NAMES BY WHICH THE REGISTRANT MAY BE KNOWN.

4. TYPE OF PROFESSIONAL FUND RAISER (CHECK ONE AND ENTER THE REQUIRED ORGANIZING INFORMATION)

CORPORATION

PARTNERSHIP

UNINCORPORATED ASSOCIATION

SOLE P ROPR IETORS HIP

STATE AND COUNTY IN WHICH ORGANIZED: ................................................................................

DATE ORGANIZED: .......................................................

5. ENTER THE REQU IRED INFORMATION FOR EACH CONTRACT AND SU BCONTRACT WITH A CHARITABLE ORGANIZATION OR OTHER ENTITY THAT

THE REGISTRANT ENTERED INTO WITHIN THE PAST 12 MONTHS, OR PROVIDED SERVICES UNDER DURING THE PAST 12 MONTHS, TO ACT AS A

PROFESSIONAL FUND RAISER OR FUND RAISING COUNSEL, EITHER WHOLLY OR PARTLY IN NEW YORK STATE.

NAME AND ADDRESS OF CONTRACTING

CONTRACT PERIOD

BRIEF DESCRIPTION OF ACTIVITIES/SERVICES

CHARITABLE ORGANIZATION OR OTHER ENTITY

(AS PER CONTRACT)

PROVIDED BY REGISTRANT

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G"X" BOX, IF ATTACHMENTS ARE INCLUDED

PURSUANT TO EXECUTIVE LAW, NONCOMPLIANCE WITH REGISTRATION REQUIREMENTS IS A MISDEMEANOR IN NEW YORK STATE

CONTINUED ON REVERSE

PRIVACY NOTIFICATION

THE DEPARTMENT OF LAW'S CHARITIES BUREAU IS REQUIRED TO COLLECT THE FEDERAL SOCIAL SECURITY AND EMPLOYER IDENTIFICATION

NUMBERS OF ALL REGISTRANTS. THE AUTHORITY TO REQUEST AND MAINTAIN SUCH PERSONAL INFORMATION IS FOUND IN §5 OF THE TAX LAW.

DISCLOSURE BY YOU IS MANDATO RY. THE INFORMAT ION IS COLLECTED TO ENABLE THE DEPARTM ENT OF TAXATION AND FINANCE TO IDENTIFY

INDIVIDUALS, BUSINESSES AND OTHERS WHO HAVE BEEN DELINQUENT IN FILING TAX RETURNS OR MAY HAVE UND ERSTATED TH EIR TAX

LIABILITIES AND TO GENERALLY IDENTIFY PERSONS AFFECTED BY THE TAXE S ADMINISTERED BY THE COMM ISSIONER OF TAXATION AND

FINANCE. IT WILL BE USED FOR TAX ADMINISTRATION PURPOSES AND ANY OTHER PURPOSE AUTHORIZED BY THE TAX LAW, BUT WILL NOT BE

AVAILABLE TO THE PUBLIC. A WRITTEN EXPLANATION IS REQUIRED WHERE NO NUMBERS ARE PROVIDED. THIS INFORMATION WILL BE

MAINTAINED IN THE CHARITIES INFORMATION SYSTEM BY THE CHARITIES BUREAU AT THE FOLLOWING ADDRESS:

STATE OF NEW YORK, DEPARTMENT OF LAW, CHARITIES BUREAU, THE CAPITOL, ALBANY, NY 12224

Form Char 013 - Professional Fund Raiser Registration Statement - 2001

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