Fund-Raising Consultant License Application

North Carolina Department of the Secretary of State Charitable Solicitation Licensing Division P.O. Box 29622 Raleigh, NC 27626 - 0622 Telephone: 919 - 814 - 5400 Fund - Raising Consultant License Application Form Issue Date: 10/21/2003 Revised 2/16/18 Page 1 of 2 1. Application Type: Initial Renewal 2. Full Business Legal Name: 4. City: State: Zip Code: City: State: Zip Code: ress: 8 Sole Proprietor/Individual Corporation General Partnership Limited Liability Corporation Limited Liability Partnership Other 9 10 11 . For non - NC corporations: P rovide either 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. A ctual webpage screenshot found on a publicly accessible regulatory authority website d ated 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 as a corporation Date the information was printed on the face of the document. For un - incorporated NC applicants: Provide a copy of your assumed name certificate fil stamp. 1 2 outside North Carolina, ATTACH list of street addresses of any applicant offices located in North Carolina. ATTACHMENT 1 2 included? Yes No NC office 1 3 directors, officers, owners, or employees? Yes No If answer is YES, attach a brief written explanation. ATTACHMENT 1 3 included? Yes 1 4 er, director, trustee, or employee of any charitable organization or sponsor under contract with applicant? Yes No If answer is YES, attach a brief written explanation. ATTACHMENT 1 4 included? Yes 1 5 ier 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 1 5 included? Yes 1 6 sons with a controlling interest in the applicant been convicted of ANY felony? Yes No If answer is YES, attach a brief written explanation . ATTACHMENT 1 6 included? Yes 1 7 sons 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 1 7 included? Yes 1 8 sons with a controlling interest in the applicant been en joined from violating ANY charitable solicitation law in this or ANY other state? Yes No If answer is YES, attach a brief written explanation. ATTACHMENT 1 8 included? 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 - 814 - 5400 Fund - Raising Consultant License Application Form Issue Date: 10/21/2003 Revised 2/16/18 Page 2 of 2 1 9 . ATTACH a list of the NAMES and PHYSICAL officers, and owners. This section must be completed for sole proprietorships, partnerships, and corporations of all types. ATTACHMENT 1 9 included? Yes 20 . ATTACH the required fee of two hundred dollars ($200.00) (make check payable to: NC Department of the Secretary of State). ATTACHMENT 20 (FEE) included? Yes 21 . D oes applicant intend to cover multiple individuals with single license? Yes No If YES, ATTACH list containing names and street addresses for ALL officers, employees, and agents of the applicant, as well as all other . ATTACHMENT 21 included?: Yes 2 2 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. I do further swear or affirm that this applicant meets the requirements of G.S. 247131F - 2(10) for acquiring and maintaining a North Carolina fund - raising consultant license in that this applicant: a. is retained by a charitable organization or sponsor for a fixed fee or rate under a written agreement to plan, manage, conduct, consult, or prepare material for the solicitation of contributions in the State of North Carolina; and b. does not solicit contributions or employ, procure, or engage any person to solicit contributions; and c. does not at any time have custody or control of contributions. Signature: 2 3 . 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., 1 st ): Day of (e.g., May): In the year of (e.g., 20 13 ): OPTIONAL APPLICANT/THIRD PARTY CONTACT INFORMATION Contact Person Name: Contact Person Title: Contact Person Business/Firm Name: American LegalNet, Inc. www.FormsWorkFlow.com