Application For Registration/renewal Of An International Student Exchange Visitor Placement Organization - Minnesota Secretary Of State, Statement Of Compliance International Student Exchange Organization Act - Minnesota Secretary Of State
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4MINNESOTA SECRETARY OF STATE
APPLICATION FOR REGISTRATION/RENEWAL OF
AN INTERNATIONAL STUDENT EXCHANGE
VISITOR PLACEMENT ORGANIZATION
Read the instructions before completing this form.
1. The name, address and telephone numbers of the organization, its chief executive officer and the officer or person who
has the primary responsibility for supervising placements within Minnesota (known as the Responsible Officer) is:
A. Organization: ______________________________________________________________________________________
(Name)
Address: ____________________________________________________________________________________________
(List the complete street address or rural route and rural route box number; a P.O. Box Number is not acceptable.)
(_____) ______________________
(Phone Number)
B. Chief Executive Officer:
______________________________________________________________________________
(Name)
Address: ____________________________________________________________________________________________
(List the complete street address or rural route and rural route box number; a P.O. Box Number is not acceptable.)
(_____) ______________________
(Phone Number)
C. Responsible Officer: ________________________________________________________________________________
(Name of employee who bears primary responsibility for the placement of students in Minnesota)
Address: ____________________________________________________________________________________________
(List the complete street address or rural route and rural route box number; a P.O. Box Number is not acceptable.)
(_____) ______________________
(Phone Number)
2. The organization’s Minnesota or nation-wide toll-free telephone number is: (_____) _______________(See instruction #2)
3. The name and address of the person responsible ensuring that the telephone number listed in item 2 is answered, is:
Name: __________________________________________________
Address: ____________________________________________________________________________________________
(List the complete street address or rural route and rural route box number; a P.O. Box Number is not acceptable.)
4. The organization is exempt from federal income tax.
Yes _____
No _____
StudentExchangeApplication Rev. 7/15/13
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