Blank Georgia S100 PDF Form

Professional Licensing Boards and Securities Division

237 Coliseum Drive

Macon, GA 31217-3858

(478)207-2440

http://www.sos.ga.gov

EXECUTION PAGE

Statutory Fees

(Nonrefundable)

Make Check Payable to Georgia Secretary of State

WARNING: The registration of a paid solicitor expires on December 31 of each year. Failure to keep this form current and file accurate supplemental information on a timely basis, or failure to keep accurate books and records or otherwise comply with provisions of the Georgia Charitable Solicitations Act of 1988, will constitute a violation of said Act and may result in disciplinary, administrative, injunctive or criminal action. INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT MAY CONSTITUTE CRIMINAL VIOLATIONS.

1. Official Name:

EXECUTION: On behalf of the applicant identified above, for the purpose of complying with the Charitable Solicitations Act of 1988 (O. C. G. A. 43- 17-1 et seq.) (“Act”), I hereby certify that the applicant is in compliance with said Act and irrevocably appoints the Secretary of State of the State of

Georgia the agent for the applicant upon whom may be served any notice, process or pleading in any action or proceeding against the applicant arising out of, or founded upon, a violation or an alleged violation of said Act. The applicant hereby consents that any such action or proceeding against said applicant may be commenced in any court of competent jurisdiction and proper venue within the State of Georgia by service of process upon Secretary of State with the same effect as if the applicant was a resident of the State of Georgia and had been personally served with process. The undersigned hereby verifies that he had executed this form on behalf of, and with the authority of, said applicant. The undersigned and applicant represent that the information and statements contained herein, including the exhibits attached hereto, and other information filed herewith, are made a part hereof, are current, true and complete. The undersigned and applicant further represent that to the extent any information previously submitted is not amended, such information is currently accurate and complete.

Official Witness (Notary)

THIS PAGE MUST ALWAYS BE COMPLETED IN FULL with original manual signature and notarization with seal. If filing an initial registration or reinstatement of registration, submit entire application. To amend, circle number(s) being amended. Registration does not become effective until all information on this application is received and approved. All paid solicitor registrations expire on December 31.

APPLICANT’S NAME:

To amend, circle numbers being amended and file with a completed execution page (S100 page 1)

4.Status of registration in other jurisdictions

Enter “1” for pending registrations, “2” if already registered, and leave blank if not registered.

ORGANIZATION

7.If FOREIGN Corporation, date qualified to transact business in Georgia:

8.Will applicant have physical possession or legal control over any contributions collected in or from the state of Georgia?

If yes, applicant must attach the following to this application:

(a)Fiscal year-end financial statement for period ending one year prior to date of filing, or for the preceding fiscal year if fiscal year has ended within 90 days of this filing OCGA 43-17-3(c)(3). ). Such financial statement must be prepared in accordance with generally accepted accounting principles.

(b)Surety bond satisfactory to the Secretary of State in the sum of $10,000 payable to the State of Georgia OCGA 43-17-4(a).

9.BRIEF DESCRIPTION OF BUSINESS. Provide a brief description of the general character of the business to be conducted or proposed to be conducted by the applicant:

CHAPTERS, BRANCHES, AND AFFILIATES

List the name and address of each affiliated branch or chapter

located in the State of Georgia and the directors of each such branch or chapter.

Attach additional sheets as needed.

APPLICANT’S NAME:

CONTROL PERSONS

The applicant must provide the following information for each person who directly or indirectly, has the power to direct or cause the direction of the management and policies of the applicant whether through the authority of voting securities, by contract or otherwise. The term control person includes, but is not limited to, each general partner, limited partner, director, affiliate or executive officer or person holding similar position.

Make additional copies of this form as needed.

(Please type or print)

Address:

The person named above MUST provide a ten year employment history

beginning with the most recent employment.

Attach separate sheets if needed.

All persons who have custody of charitable donations must submit to a criminal background check.

By signing this form the person named above authorizes the Secretary of State to conduct a criminal history check pursuant to the paid solicitor’s registration in the State of Georgia.

Signature of Control Person

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 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.A. § 50-36-1:

1) _______ I am a United States citizen 18 years of age or older. Please submit a copy of your current Secure and

Verifiable Document(s) such as driver’s license, passport, or document as indicated on pages 7 & 8 of this application.

2) _______ I am not a United States citizen, but I am a legal permanent resident of the United States 18 years of

age or older, or I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act 18 years of age or older with an alien number issued by the Department of Homeland Security or other federal immigration agency. Please submit a copy of your current immigration document(s) which includes either your Alien number or your I-94 number and, if needed, SEVIS number.

I also understand that if I have made a false statement on the application, or if I am found to have been convicted of a felony and have not had all of my civil rights restored pursuant to the law, the Commission may suspend my registration without a prior hearing. I shall be entitled to a hearing after the suspension of my registration.

I understand that I must maintain the records required by the Commission, and I shall make the records available for inspection by the Georgia Paid Solicitor Regulatory Commission, or its authorized representative, at any time during normal business hours.

In making the above attestation, I understand that any failure to make full and accurate disclosures may result in disciplinary action by the Georgia Paid Solicitor Regulatory Commission and/or criminal prosecution.

_____________________________________________________

Signature of ApplicantDate

_____________________________________________________

Print Applicant’s Name

Personally appeared before me, the undersigned official authorized to administer oaths, comes

_______________________________who deposes and swears that he/she is the person who executed this

(Applicant’s Name)

application for a license by examination for Paid Solicitor in the State of Georgia; and that all of the statements

herein contained are true to the best of his/her knowledge and belief.

Sworn to and subscribed before me this ______ day of ___________________, 2________

My Commission Expires ______________________

(seal)

APPLICANT: PLEASE CHECK THE FORM OF IDENTIFICATION BELOW THAT YOU POSSESS. RETURN THIS FORM ALONG WITH A COPY OF YOUR APPROPRIATE DOCUMENTATION.

________________________________________

Name

Secure and Verifiable Documents Under O.C.G.A. § 50-36-2

Issued August 1, 2011 by the Office of the Attorney General, Georgia

The Illegal Immigration Reform and Enforcement Act of 2011 (“IIREA”) provides that “[n]ot later than

August 1, 2011, the Attorney General shall provide and make public on the Department of Law’s website a

list of acceptable secure and verifiable documents. The list shall be reviewed and updated annually by the Attorney General.” O.C.G.A. § 50-36-2(f). The Attorney General may modify this list on a more frequent

basis, if necessary.

The following list of secure and verifiable documents, published under the authority of O.C.G.A. § 50-36-2, contains documents that are verifiable for identification purposes, and documents on this list may not necessarily be indicative of residency or immigration status.

_____ A United States passport or passport card [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

_____A United States military identification card [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

_____A driver’s license issued by one of the United States, the District of Columbia, the

Commonwealth of Puerto Rico, Guam, the Commonwealth of the Northern Marianas Islands, the United States Virgin Island, American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

_____An identification card issued by one of the United States, the District of Columbia, the Commonwealth of Puerto

Rico, Guam, the Commonwealth of the Northern Marianas Islands, the United States Virgin Island, American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

_____A tribal identification card of a federally recognized Native American tribe, provided that it contains a

photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer. A listing of federally recognized Native American tribes may be found at: http://www.bia.gov/WhoWeAre/BIA/OIS/TribalGovernmentServices/TribalDirectory/index.htm [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

_____A United States Permanent Resident Card or Alien Registration Receipt Card [O.C.G.A. § 50-36-2(b)(3); 8

CFR § 274a.2]

_____An Employment Authorization Document that contains a photograph of the bearer [O.C.G.A. § 50-36-2(b)(3); 8

CFR § 274a.2]

_____A passport issued by a foreign government [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

_____A Merchant Mariner Document or Merchant Mariner Credential issued by the United States Coast Guard

[O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

_____A Free and Secure Trade (FAST) card [O.C.G.A. § 50-36-2(b)(3); 22 CFR § 41.2]

_____A NEXUS card [O.C.G.A. § 50-36-2(b)(3); 22 CFR § 41.2]

_____A Secure Electronic Network for Travelers Rapid Inspection (SENTRI) card [O.C.G.A. §50-36-2(b)(3); 22 CFR

_____A Certificate of Naturalization issued by the United States Department of Citizenship and Immigration

Services (USCIS) (Form N-550 or Form N-570) [O.C.G.A. § 50-36-2(b)(3); 6 CFR § 37.11]

_____In addition to the documents listed herein, if, in administering a public benefit or program, an agency is required

by federal law to accept a document or other form of identification for proof of or documentation of identity, that document or other form of identification will be deemed a secure and verifiable document solely for that particular program or administration of that particular public benefit. [O.C.G.A. § secure and 50-36-2(c)]