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Professional Fund Raising Consultant Registration Statement PFC-01 - Illinois
| Professional Fund Raising Consultant Registration Statement Form. This is a Illinois form and can be used in Charitable Trusts Office Of The Attorney General Statewide . |
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Form PFC-01 PROFESSIONAL FUND RAISING CONSULTANT LISA MADIGAN Revised 3/2005 REGISTRATION STAT EMENT ATTORNEY GENERAL For The Period Beginning ____________ Through June 30, _______ PLEASE TYPE OR PRINT IN INK. Respond to all items. If unable to answer in the space provided attach a schedule in the same format. Changes of or additions to the information in this statement are to be submitted in this format. Copies of all fund raisinntractg cos must be submitted to this Office. If any of the information in this statement changes, this Office must be notified in writing within ten (10) days of the changes. All contracts between professional fund raising consultants and charitable organizamustions t be in writing and filed by the PFC with the Attorney General. Contracts shall contain the charitys lel nagame, their registration number, a street address, a contac partyt and the partys daytime telephone number. Changes or additions to the information in this statement must be submitted on this form. One of this copy Registration Statement and attachments are to be filed with tOfficehe of the Attorney General, Charitable Trust Bureau, 100 Wst Rande olph Street, 11th Floor, Chicago, Illinois 60601 1. This is a (CHECK ONE and DATE): A NEW REGISTRATION RE-REGISTRATION CHANGE ADDITION AS OF ____/____/____ REGISTRATION / REREGISTRATION 2. LEGAL For Two (2)Years UponFilingwith the Attorney General _______________________________________________________________________ _______________________________________________NAME 3. MAILING PFC#11- ________________________________________________________________________ ______________________________________________ADDRESS CITY, STATE, PHONE FEIN # ZIP CODE________________________________________________________________________ ______________________________________________NUMBER 4. A STREET ADDRESS (if different than above) ________________________________________________________________________ ______ 5. NAMES OF MANAGEMENT PERSON AND PRESIDENT______________________________________TITLE_________________________ 6. TYPE OF FIRM (Corporation, Partnership or Individual) _______________________________________________________________________ (Corporations must ATTACH Charter & Articles ILLINOIS SECRETARY OF STATES CORPORATE FILE NO. ______________________ NAME OF ILLINOIS REGISTERED AGENT _________________________________________________________________________ ______ AGENTS MAIL ADDRESS (if P.O. BOX also a street address) _________________________________________________________________ 7. GIVE PRINCIPAL ILLINOIS ADDRESS, IF ANY, AT WHICH RECORDS ARE KEPT AND NAME OF CUSTODIAN. ( NOT A P.O. BOX ) ________________________________________________________________________ ______________________________________________ 8. LIST ALL BUSINESS LOCATIONS, OTHER THAN ABOVE USED FOR FUNDRAISING. ( ATTACH SCHEDULE INDICATING ACTIVITY DESCRIPTION, STREET ADDRESS, CITY, STATE, an d if temporary location BEGINNING and ENDING USE DATES.) ________________________________________________________________________ ______________________________________________ ________________________________________________________________________ ______________________________________________ 9. IF THE REGISTRANT USES OR OPERATES UNDER ANY NAME(S) OTHER THAN THE NAME LISTED IN NUMBER 2 ABOVE, LIST ALL OTHER NAME(S) USED AND ATTACH DOCUMENTATION. (i.e., REGISTRATION UNDER THE ASSUMED NAMES ACT) ________________________________________________________________________ ______________________________________________ ________________________________________________________________________ ______________________________________________ 10. LIST ALL PRINCIPAL PARTIES, OFFICE RS, DIRECTORS, EXECUTIVE PERSONNEL, AND OWNERS OF TEN PERCENT OR MORE OF THE CAPITAL STOCK. (ATTACH SCHEDULE IF NECESSARY) NAME STREET ADDRESS TITLE % OF INTEREST ________________________________________________________________________ ___________________________________________ ________________________________________________________________________ ___________________________________________ ________________________________________________________________________ ___________________________________________ ________________________________________________________________________ ___________________________________________ American LegalNet, Inc. www.USCourtForms.com <<<<<<<<<********>>>>>>>>>>>>> 211. LIST ALL PRINCIPAL PARTIES, OFFI CERS, DIRECTORS, EXECUTIVE PERSONNEL, AND OWNERS OR FAMILY MEMBERS OF REGISTRANT HAVING ANY OWNERSHIP INTER EST IN ANY OTHER FIRMS PROVIDING GOODS OR SERVICES USED IN FUND RAISING. NAME of PARTY NATURE OF BUSINESS % IN TEREST NAME and STREET ADDRESS of BUSINESS _______________________________________________________________________ _______________________________________________ _______________________________________________________________________ _______________________________________________ ________________________________________________________________________ ______________________________________________ 12. LIST THE INFORMATION REQUESTED BELOW FOR ALL CHARITABLE ORGANIZATIONS HAVING CONTRACTS WITH REGISTRANT, WHICH ARE OR WILL BE IN EFFECT DURING THE REGISTRATION PERIOD INVOLVING THE RAISING OF FUNDS IN ILLINOIS AND ATTACH COPIES OF THE CONTRACTS. CHARITY REGISTRATION # LEGAL NAME a nd STREET ADDRESS of CHARITABLE ORGANIZA TION FROM and TO DATES (MM/DD/YY) ________________________________________________________________________ _____________________________________________ ________________________________________________________________________ _____________________________________________ ________________________________________________________________________ _____________________________________________ 13. IS THE REGISTRANT LICENSED BY , REGISTERED WITH OR HAVE A PERMIT FROM ANY OTHER GOVERNMENTAL AGENCY FOR THE PURPOSE OF PROVIDING FUND RAISING COUNSEL FOR CHARITABLE ORGANIZATIONS Yes No IF YES LIST THE FOLLOWING INFORMATION: NAME and ADDRESS of GOVERNMENTAL AGENCY DATE of AUTHORIZATION(Month/Day/Year) ________________________________________________________________________ ______________________________________________ 13. HAS THE REGISTRANT HAD ANY LICENSE, REGISTRATION OR PERMIT DENIED, CANCELLED OR REVOKED, OR IS ANY SUCH ACTION PENDING? Yes No IF YES ATTACH A SCHEDULE INDICATING NAME and ADDRESS of GOVERNMENTAL AGENCY, NATURE of ACTION, DATE of ACTION. 14. HAS ANY GOVERNMENT
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