Form Boe-232 - Annual Certification Regarding Solicitation Activities Page 2
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1
2BOE-232 BACK (9-12)
ANNUAL CERTIFICATION OF NO SOLICITATION
(to be completed by persons operating in California)
I HEREBY CERTIFY, UNDER PENALTY OF PERJURY:
That the person named below is operating under an agreement with
___________________________________________
_
OUT-0F-STATE RETAILER’S NAME
and the person named below has not engaged in prohibited solicitation activities in California that refers potential
customers to
__________________________________
________
at any time during the previous year
________________
.
OUT-0F-STATE RETAILER’S NAME
XX-XX-XX TO XX-XX-XX
The prohibited solicitation activities include, but are not limited to, distributing flyers, coupons, newsletters, and other
printed promotional materials or electronic equivalents, verbal soliciting (for example, in-person referrals), initiating
telephone calls, and sending emails.
PERSON’S NAME
SIGNATURE OF PERSON OR PERSON’S AUTHORIZED REPRESENTATIVE
DATE
PRINTED NAME OF PERSON SIGNING
TITLE
TELEPHONE NUMBER
(
)
ADDRESS OF PERSON SIGNING (street, city, state, zip code)
ADDRESS OF PERSON’S AUTHORIZED REPRESENTATIVE WHEN APPLICABLE (street, city, state, zip code)
ADDITIONAL STATEMENT FROM ORGANIZATION
(to be completed by organizations)
I HEREBY CERTIFY, UNDER PENALTY OF PERJURY:
That the website of the organization named below includes information that alerts its members that anyone operating
under the organization’s agreement with
___________________________________________________________
ORGANIZATION’S NAME
is prohibited from engaging in any solicitation activities in California that refers potential customers to
________________________________________________________
, including, but not limited to, distributing flyers,
OUT-OF-STATE RETAILER
coupons, newsletters, and other printed promotional materials or electronic equivalents, verbal soliciting (for example,
in-person referrals), initiating telephone calls, and sending emails.
ORGANIZATION’S NAME
SIGNATURE OF ORGANIZATION’S AUTHORIZED REPRESENTATIVE
DATE
PRINTED NAME OF AUTHORIZED REPRESENTATIVE
TITLE
TELEPHONE NUMBER
(
)
ADDRESS OF AUTHORIZED REPRESENTATIVE (street, city, state, zip code)
ADDRESS OF ORGANIZATION (street, city, state, zip code)
ORGANIZATION’S WEBSITE
CLEAR
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