Rhode Island > Secretary Of State > Blue Sky > Securities
Application For Professional Fundraiser - Rhode Island
| Application For Professional Fundraiser Form. This is a Rhode Island form and can be used in Securities Blue Sky Secretary Of State . |
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STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS Department of Business Regulation CHARITABLE ORIGINATION SECTION 1511 Pontiac Avenue John O. Pastore Complex BLDG 69-1 Cranston, RI 02920 APPLICATION FOR PROFESSIONAL FUNDRAISER FILINGS MUST BE SUBMITTED ON CD-ROM. WE NO LONGER ACCEPT PAPER FILINGS E-mail Address___________________________ EIN #: __________________________________ ANNUAL FEE: $240.00 INITIAL APPLICATION RENEWAL APPLICATION CHECKS PAYABLE TO: GENERAL TREASURER STATE OF RI ANNUAL EXPIRATION: JUNE 30TH 1. NAME OF ORGANIZATION: ________________________________________________ 2. ADDRESS: ________________________________________________________________ 3. DATE/PLACE OF ORGANIZATION: __________________________________________ 4. FORM OF ORGANIZATION: _________________________________________________ 5. ATTACH BOND, if required by R.I.G.L. 5-53.1-8__________________________________ (If bond is not required pursuant to R.I.G.L. 5-53.1-8, indicate this on the line above.) 6. SUBMIT COPIES OF ALL CONTRACTS WITH CHARITABLE ORGANIZATIONS. (Must be submitted within ten (10) days after signing, pursuant to R.I.G.L. 5-53.1-9) 7. ATTACH NAMES AND ADDRESSES OF ALL OFFICERS, AGENTS & EMPLOYEES. 8. CONTACT PERSON AND MAILING ADDRESS:________________________________ ____________________________________________________________________________ 9. HAS ANY GOVERNMENT AGENCY OR COURT ENJOINED THE APPLICANT, ITS DIRECTORS, MEMBERS, TRUSTEES, SENIOR LEVEL EXECUTIVES, EMPLOYEES OR SUB-CONTRACTORS FROM SOLICITING CONTRIBUTIONS? YES ____ NO ____ IF YES, PLEASE DESCRIBE: 10. HAS APPLICANT'S LICENSE OR REGISTRATION BEEN SUSPENDED OR CANCELED BY ANY GOVERNMENTAL AGENCY. YES ____ NO ____ IF YES, PLEASE DESCRIBE: ___________________________________________________ _____________________________________________________________________________ Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 11. HAS ANY DIRECTOR, OFFICER, MEMBER, TRUSTEE, PARTNER, SENIOR LEVEL EXECUTIVE, EMPLOYEE, OR SUBCONTRACTOR OF THE PROFESSIONAL FUNDRAISER BEEN CONVICTED OF A FELONY, PLED NOLO CONTENDERE TO A FELONY CHARGE, OR BEEN HELD LIABLE IN A CIVIL ACTION INVOLVING FRAUD, EMBEZZLEMENT, FRAUDULENT CONVERSION OR MISAPPROPRIATION OF PROPERTY? YES _____NO _____ IF YES, PLEASE PROVIDE DETAILS: 12. SUBMISSION OF TAXPAYER STATUS AFFIDAVIT (ATTACHED TO APPLICATION AS EXHIBIT 1) I CERTIFY UNDER PENALTY OF PERJURY THAT I HAVE READ THIS APPLICATION AND KNOW THAT ALL STATEMENTS THEREIN ARE TRUE _____________________________________ (Signature) _________________________ (Date) ___________________________________________________________ (Print Name, title and Phone Number) NOTARY: ` (PROFESSIONAL FUNDRAISER FORM) (REV. 01/2010) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com State of Rhode Island and Providence Plantations Department of Business Regulation Securities Division 1511 Pontiac Avenue John O. Pastore Complex Building 69-1 Cranston, RI 02920 TEL: (401) 462-9527 FAX: (401) 462-9645 TDD: 711 www.dbr.state.ri.us EXHIBIT 1 MANDATORY ADDENDUM TO LICENSE APPLICATION Tax Payer Status Affidavit / Identity Verification All persons applying or renewing any license, registration, permit or other authority (herein after called "licensee") to conduct a business or occupation in the state of Rhode Island are required to file all applicable tax returns and pay all taxes owed to the state prior to receiving a license as mandated by state law (RIGL §5-76-2) except as noted below. In order to verify that the state is not owed taxes, licensees are required to provide their Social Security Number, or Federal Tax Identification Number (for businesses) as appropriate. These numbers will be transmitted to the Division of Taxation to verify tax status prior to the issuance of a license. PLEASE CHECK ONE BOX ONLY, EVEN IF YOU HAVE NEVER BEEN EMPLOYED IN RHODE ISLAND. Licensee Declaration I hereby declare, under penalty of perjury, that I have filed all required state tax returns and have paid all taxes owed. I have entered a written installment agreement to pay delinquent taxes that is satisfactory to the Tax Administrator. I am currently pursuing administrative review of taxes owed to the state. I am in federal bankruptcy. (Case # ) I am in state receivership. (Case # ) I have been discharged from Bankruptcy. (Case # ) Type of Professional/Business License for which you are applying Full Name (Please Print or Type) Signature Date Social Security Number (or FEIN for Business) Phone Number (including area code if not 401) Name of Business (If Applicable) NOTE: This form must be completed, signed and attached electronically to your application in order for us to begin processing. Please call the Department with any questions. Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com
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