Registration Statement For A Charitable Organization - South Carolina Secretary Of State Page 4
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416. If your organization intends to use a professional solicitor, professional fundraising counsel, or commercial co-
venturer, or hire individuals to solicit, please list their names and contact information. Attach a list if necessary.
_______________________________________________________________
___________________________
Name
Phone
______________________________________________________________________________________________
Address, City, State, Zip Code
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 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 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
* The persons signing this form as CEO/President and CFO/Treasurer must be designated as such on the current
fiscal year’s list of officers, directors, trustees, and board members. If not, the registration will be returned for
correction.
Charities Registration Statement, Revised December 2016
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