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Application For Registration As Solicitor Agent SA-1 - Georgia
|Application For Registration As Solicitor Agent Form. This is a Georgia form and can be used in Securities And Business Regulation Blue Sky Secretary Of State .||
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Professional Licensing Boards and Securities Division 237 Coliseum Drive Macon, GA 31217-3858 (478) 207-2440 http://www.sos.state.ga.us/securities/ Brian P. Kemp Secretary of State Eric R. Lacefield Division Director Application for Registration as a Solicitor Agent Pursuant to The Georgia Charitable Solicitation Act of 1988, As Amended Initial Registration - $ 50.00 Amendment - $15.00 Reinstatement - $50.00 INSTRUCTIONS: THIS APPLICATION MUST BE COMPLETED AND FILED BEFORE SOLICITING CHARITABLE CONTRIBUTIONS. ALL AGENT REGISTRATIONS EXPIRE ON DECEMBER 31. ANSWER ALL QUESTIONS COMPLETELY, ATTACHING ADDITIONAL PAGES IF MORE SPACE IS NEEDED. CHECKS SHOULD BE MADE PAYABLE TO THE SECRETARY OF STATE. AMENDMENTS TO THIS REGISTRATION SHOULD BE FILED PROMPTLY, USING THIS FORM, TO REFLECT ANY CHANGES IN THE INFORMATION SUBMITTED. 1. (a) Full Name of Applicant: _____________________________________________________________________________________ (b) Home Address: ____________________________________________________________________________________________ (Address) ____________________________________________________________________________________________________________ (City) (State) (Zip) (Telephone No.) 2. Address of Each Place of Business: _______________________________________________________________________________ (Address) ____________________________________________________________________________________________________________ (City) (State) (Zip) (Telephone No.) 3. Identify the name(s) and address(s) of Paid Solicitor or Fundraising Counsel with which Agent will be affiliated. Indicate if affiliation is as an employee or as an independent contractor. Attach additional pages as needed. Employee Independent Contractor ____________________________________________________________________________________________________________ Name of Paid Solicitor/Fundraising Counsel SOS Registration No. ____________________________________________________________________________________________________________ (Address) ____________________________________________________________________________________________________________ (City) (State) (Zip) ____________________________________________________________________________________________________________ Contact Person Telephone No. 4. 5. If Applicant is an independent contractor, attach a copy of contract(s) indicated on #3. Attach a list of all other sates in which Applicant is registered. Form SA-1 Revised Aug 2012 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 6. In the past ten years has the applicant been convicted of or pled guilty or nolo contendere (no contest) to a felony or misdemeanor which: (A) Involves the solicitation or acceptance of charitable contributions or the making of a false oath, the making of a false report, bribery, perjury, burglary, or conspiracy to commit any of the foregoing offenses? Yes No (B) Arises out of the conduct of solicitation of contributions for a charitable organization? Yes No (C) Involves the larceny, theft, robbery, extortion, forgery, counterfeiting, fraudulent concealment, embezzlement fraudulent conversion, or misappropriation of funds? Yes (D) Involves murder or rape? No No No Yes No (E) Involves assault or battery if such person proposes to be engaged in counseling, advising, housing, or sheltering of individuals? Yes Yes 7. 8. (F) Pled guilty or nolo contendere (no contest) to any other felony offense? Has any registration in any state ever been denied, revoked, suspended, or withdrawn? Yes No Has Applicant ever been subject to any injunction or disciplinary proceeding by any state agency involving any aspect of fund raising or solicitation? Yes No Has Applicant ever been subject to an order, consent order or any other disciplinary or administrative proceeding pursuant to the unfair and deceptive acts and practices law of any state? 9. Yes No If the answer is "yes" to any of the aforementioned questions or if such proceeding is pending in any state, attach all pertinent information with respect to such injunction, disciplinary proceeding, conviction or charges. If the applicant is seeking to be qualified to contact contributors and potential contributors in person, the applicant, by signing this application, gives the Office of the Secretary of State authorizes to conduct a criminal history background investigation. 10. Will applicant solicit contributions in person, as distinguished from mail, telephonic or electronic contact? Yes If the answer is "yes", provide: Social Security Number: __________________________________ No Date of Birth: ____________________________________ SOLICITOR AGENT CERTIFICATION The undersigned applicant represents that the information and statements contained in this application, including the attached exhibits, are current, true and complete. The undersigned further represents that to the extent any information previously submitted is not amended, such information is currently accurate and complete. By signing this certification, the applicant certifies that he/she is at least 18 years of age and that willful misstatements or omissions of fact may result in administrative, civil or criminal action. _________________________________________________________________ Print Name of Applicant _________________________________________________________________ Signature of Applicant ____________________________ Date Sworn to and subscribed before me this _________ Day of _________________________, 20_________ Notary Public ____________________________________________My Commission Expires: _______________________________ Form SA-1 Revised Aug 2012 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT OF APPLICANT I certify and declare that I am of good moral character and that all information contained in this application is true and correct, to the best of my knowledge. I understand that any willful omission or falsification of pertinent information required in the application is justification for the denial, suspension, or revocation of my registration by the Commission. I further swear and affirm that I have read and understand the current state laws and rules and regulations of the Georgia Paid Solicitor Agent Regulatory Commission and I agree to abide by these laws and rules, as amended from time to time. By signing this application, electronically or otherwise, I hereby swear and affirm one of the following to be true and accurate pursuant to O.C.G.