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3201
Form
(Revised 03/15)
Submit to:
Secretary of State
Registrations Unit
Public Safety Organization,
P.O. Box 13550
Independent Promoter, or
Austin, TX 78711-3550
512 475-0775
Public Safety Publication
FAX: 512 475-2815
Registration Statement
Filing Fee: $250.00
____
New
____
Renewal
(Please print or type and attach additional sheets if necessary)
1.
Registrant's Name:
_____________________________________________________________
Type of organization: (Corporation, unincorporated entity, partnership, etc.)
_______________________________________________________________________________
Street Address:
_________________________________________________________________
Mailing Address:
_______________________________________________________________
Telephone Number: (
__________ _________________________________________________
)
2.
List below the name, street address, and telephone number of each solicitor that will solicit on
behalf of the registrant.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
3.
List the name, street address, and telephone number of each public safety organization, public
safety publication, or fund on behalf of which all or part of the contributions will be used, or if there
is no organization, publication, or fund, a statement describing the manner in which the
contributions will be used.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
4.
Does the registrant or fund for which the contributions are to be solicited have a charitable
tax exemption under federal law?
_________________
Under state law?
_________________
What is the basis for the exemption?
_______________________________________________
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