Registration Statement For Professional Fundraising Counsel {BCO-150}

(Rev. 10-12) (717) 783-1720 1-800-732-0999 (WITHIN PA) FAX (717) 783-6014 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CHARITABLE ORGANIZATIONS 207 NORTH OFFICE BUILDING HARRISBURG, PA 17120 Web site: www.dos.state.pa.us/charities REGISTRATION STATEMENT FOR PROFESSIONAL FUNDRAISING COUNSEL - FORM BCO-150 INITIAL RENEWAL (CHECK ONE ABOVE) CERTIFICATE # ______________ (RENEWAL APPLICANTS ONLY) FEE REMITTED ___________ EMPLOYER IDENTIFICATION NUMBER (EIN): 1. Business name of applicant: FULL BUSINESS NAME Check if name change 2. Contact person: Contact's E-mail: Previous name: Address for the principal place of business: (Required) Mailing address: (If different than principal) City: State: County: Phone number: 800 number: E-mail (If different than Contact's E-mail): Web site: 3. Any other names under which you conduct business: Zip code: City: State: Zip code: Fax number: 4. Form of organization: a. Corporation (State of Incorporation and Date) b. Partnership c. Individual d. Other 5. If principal place of business is located outside Pennsylvania, do you have any offices in Pennsylvania? Yes No If "Yes", attach address(es) and telephone number(s). 6. If "Yes" to any of the following you must register as a professional solicitor: (A) Will you at any time solicit contributions? Yes No (B) Will you have sole control and approval over the content and volume of any solicitations that are conducted by a charitable organization? Yes No (C) Will you at any time have custody or control of contributions? Yes No No (D) Will your compensation be related to the amount of contributions received? Yes 5 American LegalNet, Inc. www.FormsWorkFlow.com 7. Attach a list of the names and residence addresses of all principals of the applicant, including officers, directors and owners. An applicant formed as an individual is required to list his/her self as a principal. 8. Provide the name of all persons in charge of any counsel services. This includes those that provide counsel services and those that supervise. 9. If you answer "Yes" to any of the following, attach a list of related individuals with names and relationship. Are any owners, directors, officers or employees of the applicant related by blood, marriage or adoption to: (A) Any other directors, officers, owners or employees of the applicant? Yes No (B) Any officer, director, trustee or employee of any charitable organization under contract with applicant? Yes No (C) Any supplier or vendor providing goods or services directly or indirectly to any charitable organization under contract with applicant? Yes No 10. Are all contracts with charitable organizations soliciting contributions from Pennsylvania residents on file with, and approved by, the Bureau as required by Section 162.8 (d) of the Solicitation of Funds for Charitable Purposes Act? Yes No Not Applicable . If "No", attach copies. File only those contracts regarding your providing of services with respect to a charitable organization's solicitation of contributions from Pennsylvania residents. Renewal registrants, should not re-file contracts previously filed and approved by the Bureau. Item 11 need only be completed by initial registrants 11. Date organization first acted as a professional fundraising counsel with respect to a charitable organization's solicitation of contributions from Pennsylvania residents: ____/____/____ (If not applicable, please state such). I certify that the information provided in this registration, including all statements and documentation is true and correct. I understand that the falsification of any statement or documentation is subject to criminal penalties for unsworn falsifications pursuant to 18 Pa. C.S. Sec. 4904. DATE SIGNATURE OF PRINCIPAL OFFICER OF THE PROFESSIONAL FUNDRAISING COUNSEL TYPE OR PRINT NAME AND TITLE OF PRINCIPAL OFFICER CHECKLIST Registration Statement signed. Any attachment(s) to the Registration Statement. Any contracts not previously filed and approved. $250 registration fee by a check or money order made payable to the Commonwealth of Pennsylvania. 6 American LegalNet, Inc. www.FormsWorkFlow.com