Solicitor License Application | Pdf Fpdf Doc Docx | North Carolina

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Solicitor License Application | Pdf Fpdf Doc Docx | North Carolina

Solicitor License Application

This is a North Carolina form that can be used for Charitable Solicitation Licensing within Secretary Of State.

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North Carolina Department of the Secretary of State Charitable Solicitation Licensing Division P.O. Box 29622 Raleigh, NC 27626-0622 Telephone: 919-807-2214 1. Application Type: Initial Renewal Solicitor License Application Form Issue Date: 10/22/2003 Revised 1/1/2013 Page 1 of 2 2. Applicant's Full Business Legal Name: 4. Applicant's Principal Street Address: 3. Applicant's Principal Telephone Number: City: 5. Applicant's Mailing Address: State: Zip Code: City: State: Zip Code: OPTIONAL APPLICANT/THIRD PARTY CONTACT INFORMATION Contact Person Name: Internet Site Address: Contact Person's Telephone Number: 6. Legal Form of Applicant's Business: Sole Proprietor / Individual Limited Liability Corporation 7. Applicant's State of Establishment: Corporation General Partnership Contact Person Title: Contact Person's Electronic Mail Address: Contact Person's Facsimile Number: Limited Liability Partnership Other _____________________ 8. Applicant's Date of Establishment: 9. For non-NC corporations: Provide either of the following to verify the applicant's current legal existence: 1. Certificate of Existence or Certificate of Good Standing from state of incorporation dated no more than six months prior to date of signing of application, or 2. Actual webpage screenshot found on a publicly accessible regulatory authority website dated no more than thirty (30) days prior to the date the license application was signed that includes the following elements: · Exact name of the entity as it appears on the license application; and · Language clearly verifying its status in good standing in the state of incorporation (i.e. "current" or "active"); and · Date the information was printed on the face of the document. For non incorporated applicants: Copy of stamped certificate of "doing business as" or "assumed name" filed with local Register of Deeds must be filed with application. 10. If applicant's principal place of business is located outside North Carolina, ATTACH list of street addresses of any applicant offices located in North Carolina. ATTACHMENT 10 included? Yes No NC Offices 11. Are ANY of applicant's' owners, directors, officers, or employees RELATED as parent, spouse, child, or sibling to ANY of applicant's other directors, officers, owners, or employees? Yes No If answer is YES, attach a brief written explanation. ATTACHMENT 11 included? Yes 12. Are ANY of applicant's' owners, directors, officers, or employees RELATED as parent, spouse, child, or sibling to ANY officer, director, trustee, or employee of any charitable organization or sponsor under contract with applicant? Yes If answer is YES, attach a brief written explanation No Yes ATTACHMENT 12 included? 13. Are ANY of applicant's' owners, directors, officers, or employees RELATED as parent, spouse, child, or sibling to ANY supplier or vendor providing goods or services to any charitable organization or sponsor under contract with the applicant? Yes No If answer is YES, attach a brief written explanation. ATTACHMENT 13 included? 14. Within the last five (5) years, has the applicant, or any of the applicant's directors, officers, employees, agents, or persons with a controlling interest in the applicant: been convicted of ANY felony? Yes No If answer is YES, attach a brief written explanation. ATTACHMENT 14 included? Yes Yes American LegalNet, Inc. www.FormsWorkFlow.com North Carolina Department of the Secretary of State Charitable Solicitation Licensing Division P.O. Box 29622 Raleigh, NC 27626-0622 Telephone: 919-807-2214 Solicitor License Application Form Issue Date: 10/22/2003 Revised 1/1/2013 Page 2 of 2 15. Within the last five (5) years, has the applicant, or any of the applicant's directors, officers, employees, agents, or persons with a controlling interest in the applicant been convicted of ANY misdemeanor arising from the conduct of a solicitation for ANY charitable organization or sponsor OR charitable or sponsor purpose? Yes No If answer is YES, attach a brief written explanation. ATTACHMENT 15 included? 16. Within the last five (5) years, has the applicant, or any of the applicant's directors, officers, employees, agents, or persons with a controlling interest in the applicant been enjoined from violating ANY charitable solicitation law in this or ANY other state? Yes No If answer is YES, attach a brief written explanation. ATTACHMENT 16 included? 17. ATTACH a list of the NAMES and PHYSICAL RESIDENCE ADDRESSES of ALL of applicant's officers, directors, and owners. This section must be completed for sole proprietorships, partnerships, and corporations of all types. ATTACHMENT 17 included? 18. ATTACH a list of the NAMES of ALL persons in charge of ANY solicitation activity. ATTACHMENT 18 included? 19. ATTACH the required fee of two hundred dollars ($200.00) (make check payable to: NC Department of the Secretary of State). ATTACHMENT 19 (FEE) included? 20. If Partnership or Corporation, does applicant intend to cover multiple individuals with single license? Yes Yes Yes Yes Yes Yes No If YES, ATTACH list containing names and street addresses for ALL partners, members, officers, directors, employees, and agents of the applicant, as well as all other individuals contracted to work under applicant's direction. ATTACHMENT 20 included?: Yes 21. ATTACH appropriate BOND or other surety required by N.C.G.S. 131F-16(d) in the appropriate amount as follows: Contributions received in last fiscal year Up to $100,000 Up to $200,000 $200,000 and over 22. Applicant's signature: Required Bond Amount $20,000 $30,000 $50,000 ATTACHMENT 21 (BOND) included? Yes I do hereby swear or affirm that the information furnished in this application and all supplemental forms, reports, documents, and attachments are true and correct to the best of my knowledge under penalty of perjury. Signature: _____________________________________________________ Signer's Name (Print): Signer's Title (Print): 23. Notarization: The following is for a notary public to place you under oath and then notarize YOUR signature: (County)_________________________________(State)__________________________________________ County and State in which oath or affirmation taken Notary Stamp or Seal goes Here Sworn to and subscribed before me this the (e.g., 1st): Day of (e.g., May): Notary Public's Signature: Notary Public's Name (Print): Date Notary Public's Commission Expires: In the year of (e.g., 2013): American LegalNet, Inc. www.FormsWorkFlow.com

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