Form Dacs-10100e - Registration Statement - Florida Department Of Agriculture & Consumer Services

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DEPARTMENT OF AGRICULTURE & CONSUMER SERVICES
SOLICITATION OF CONTRIBUTIONS ACT - REGISTRATION STATEMENT
_
FLORIDA DEPARTMENT OF AGRICULTURE & CONSUMER SERVICES
Make check payable and remit application to:
REGISTRATION STATEMENT
Florida Department of Agriculture &
Consumer Services
SOLICITATION OF CONTRIBUTIONS ACT
Post Office Box 6700
Chapter 496, Florida Statutes
Tallahassee, Florida 32314-6700
CHARLES H. BRONSON
1-800-HELP FLA
COMMISSIONER
(435-7352)(FL Only)
Note: All documents and attachments submitted with this Application are subject to public review pursuant to Chapter 119, F.S.
PLEASE TYPE OR PRINT. Additional pages may be attached if additional space is needed. Please ensure that all
attachments reflect the organization’s name or registration number and the number of the corresponding question.
REGISTRATION STATEMENT TYPE: (Check applicable box.)
Charitable
Sponsor
Professional Solicitor
[496.404(1)]
[496.404(21)]
[496.404(18)]
Charitable/Parent
Sponsor/Parent
Professional Fundraising Consultant
[496.404(15)]
[496.404(15)]
[496.404(17)]
1. Legal name of organization
[496.405(2)(b), 496.405(2)(g)1, 496.409(2)(a), 496.410(2)(a), F.S.]
__________________________________________________________________________________________
Previous name, if changed: _____________________________________________________________________
Other names soliciting as:
a.____________________________________________________________________
b.____________________________________________________________________
c.
2. Street address________________________________________________________________________________
City__________________________________State_________________________Zip Code__________________
Mailing address (if different)_____________________________________________________________________
City__________________________________State_________________________Zip Code__________________
3. Telephone number____________________________
Fax number_________________________________
E-mail_____________________________________
Solicitation of Contributions
Org Code: 42100304000-A2
Object Code: 001133
Web site___________________________________
1 of 9
DACS-10100E
(Revised 05/03/2002)

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