Registration Application For A Commercial Co-Venturer Form Page 2
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25.
Please provide a list of all current officers and directors of the company, along with their addresses.
6.
Is the company currently registered in any other state as a commercial co-venturer?
____No ____ Yes If yes, provide a list of all states where registered.
7.
Please provide a list of all charitable organizations with which the company has an active contract in South Carolina.
8.
Please attach a list of all charitable organizations with which the company has contracted in South Carolina for
the previous three years.
9.
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.
10. 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, false
statement, forgery, or theft, including identity theft, in a jurisdiction within the United States?
____No ____ Yes If yes, provide a full description and the date of any such conviction.
11. Are any of the officers, directors, trustees, or board members of the commerical co-venturer applicant related to each
other? ____No ____ Yes If yes, provide a full description.
12. Are any of the officers, directors, trustees, or board members of the commercial co-venturer applicant related to any
director, agent, or employee of a charitable organization under contract with the commercial co-venturer?
____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
Registration Application, Commercial Co-venturer, Revised September 2015
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