Name of Bonding Company: ____________________________________________________
Bond Number: ________________________
Bond Expiration Date: _______________________________
5. Please provide a list of all charitable organizations for which you have an active contract in South Carolina.
6. Please provide a list of all current officers and directors, along with their addresses and phone numbers.
7. Please provide a list of all officers, directors, individual owners or partners for the preceding three years.
8. Please provide a list of all employees, their job titles, and whether full time, part-time, or contracted.
9. Please attach a list of all charitable organizations with which you have contracted in the State of South Carolina for
the previous three years.
10. Are you currently registered in any other state as a Professional Fundraiser, Professional Solicitor, or a Professional
Fundraising Counsel? ____No ____ Yes If yes, provide a list of all states where registered.
11. Do you ever have custody of contributions or any financial records of contributions of the charitable organization with
which you are contracted?____No ____ Yes If yes, provide a list of individuals who serve as couriers or employees
to personally collect contributed funds from solicited parties.
12. Is any principal officer, director, owner or partner of the applicant also an officer, director, board member, shareholder,
owner or partner of any nonprofit or charitable organization? ____No ____ Yes If yes, provide a full description.
13. Has the applicant, or its directors, principal officers, individual owners, or partners been the subject of a legal or
administrative action, including an injunction concerning a charitable solicitation, fundraising campaign, or campaign
with a commercial co-venturer by another local, state, or federal governmental authority including, but not limited to
registration or license revocation or denial, fines, injunctions, suspensions, or voluntary agreement to discontinue any
charitable solicitation activity? ____No ____ Yes If yes, provide a full description.
14. Has the applicant, or its directors, principal officers, individual owners, or partners been the subject of a criminal
conviction, including guilty or nolo contendere pleas, involving any charitable solicitations act, fraud, dishonesty, or
false statement in a jurisdiction within the United States? ____No ____ Yes If yes, provide a full description and
the date of any such conviction.
15. Are any of the officers, directors, trustees, or board members of the professional fundraising counsel or professional
solicitor applicant related to each other? ____No ____ Yes If yes, provide a full description.
16. Are any of the officers, directors, trustees, or board members of the professional fundraising counsel or professional
solicitor applicant related to any director, agent, or employee of a charitable organization under contract with the
professional fundraising counsel or solicitor? ____No ____ Yes If yes, provide a full description.
I certify that the information furnished in this application and all attached supplementary information is true and correct to
the best of my knowledge, information and belief. I understand that the giving of false or incorrect information may
constitute a misdemeanor carrying a penalty upon conviction of a fine of not more than two thousand dollars ($2,000.00) or
imprisonment for not more than one year, or both, for a first offense. A second or subsequent offense may constitute a
felony carrying a penalty upon conviction of a fine of not more than five thousand dollars ($5,000.00) or imprisonment of
not more than five years, or both.
CHIEF FINANCIAL OFFICER / TREASURER
CHIEF EXECUTIVE OFFICER / PRESIDENT
_________________________________________
_________________________________________
Print Name
Print Name
_________________________________________
_________________________________________
Signature
Date
Signature
Date
_________________________________________
_________________________________________
Mailing Address
Mailing Address
_________________________________________
_________________________________________
City, State, Zip
City, State, Zip
_________________________________________
_________________________________________
Phone Number
Phone Number
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