§400.ILLUSTRATION A. Registration Statement

Form PS-01

PROFESSIONAL  SOLICITOR -REGISTRATION  STATEMENT-

JIM RYAN ATTORNEY GENERAL

PLEASE TYPE OR PRINT IN BLACK INK.  Respond to all items. If unable to answer in space provided attach a schedule in the same format.  Changes of or additions to the information in this statement are to be submitted in this format.  Due to the  large volume of reports and registrations handled by this division, we will not consider a partial registration.  This form must be complete and accompanied by any supporting documents.  A copy of this form must be retained by the Professional Fund Raiser who intends to employ this party.  One copy of this Registration Statement and attachments are to be filed with the Attorney General's Office, Charitable Trust and Solicitations Bureau,  100 West Randolph Street, Chicago, Illinois 60601.

1.

THIS IS A (CHECK ONE and DATE):

NEW REGISTRATION    REREGISTRATION    CHANGE    ADDITION , AS OF

/       /

2.

LEGAL NAME

REGISTRATION/REREGISTRATION

For Fiscal Year Ending June 30,  ______

3.

MAIL ADDRESS

PFR NUMBER

02-

CITY, STATE, ZIP CODE

PHONE NUMBER

SOCIAL SECURITY NUMBER

4.

This PROFESSIONAL SOLICITOR intends to be employed by (PFR)

(NAME OF PFR)

5.

A STREET ADDRESS (if different than above)

6.

BIRTH DATE

/        /

DRIVER'S LICENSE NO.

STATE OF ISSUE

7.

IF THE ADDRESS ABOVE IS NOT IN ILLINOIS, LIST PRINCIPAL ILLINOIS ADDRESS, IF ANY, A STREET ADDRESS ONLY (NOT A P.O. BOX)

8.

LIST NAME AND DAYTIME TELEPHONE NUMBER OF A FAMILY MEMBER OR ANOTHER PERSON WHO CAN CONTACT YOU IN THE EVENT YOU ARE NO LONGER AT THE ABOVE ADDRESS.

RELATIONSHIP

9.

LIST ALL PAST, PRESENT AND ANTICIPATED EMPLOYMENT AS A PROFESSIONAL SOLICITOR.  THROUGH THE END OF THE FISCAL YEAR INDICATE ALL TERMS OF COMPENSATION. BE SPECIFIC: INDICATE ACTUAL RATE PER HOUR, % OF FUNDS or OTHER ARRANGEMENT.

NAME and ADDRESS of PROFESSIONAL FUND RAISER

TERMS of COMPENSATION

FROM and To Dates (Month/Day/Year)

10.

ARE YOU LICENSED, REGISTERED OR HAVE A PERMIT FROM ANY OTHER STATE OR GOVERNMENTAL BODY FOR SOLICITING

FUNDS FOR CHARITABLE ORGANIZATIONS?   YES    NO  IF "YES" COMPLETE THE FOLLOWING:

NAME and ADDRESS of STATE or GOVERNMENT

DATE of AUTHORIZATION

11.

ARE YOU TO RECEIVE, FOR TAX PURPOSES, A W-2 OR 1099 FROM PFR?    YES    NO

12.

HAS ANY LICENSE OR PERMIT BEEN DENIED, CANCELED OR REVOKED, OR HAS ANY ACTION BEEN TAKEN

AGAINST YOU IN CONNECTION WITH SOLICITATION OF FUNDS FOR CHARITABLE PURPOSES?    YES    NO

IF "YES"  COMPLETE THE FOLLOWING:

NAME and ADDRESS of GOVERNMENTAL AGENCY

NATURE and DATE of ACTION

13

ARE YOU AN EMPLOYEE OF OR INDEPENDENT CONTRACTOR WITH THE PER?

14.

HAVE YOU EVER BEEN CONVICTED OF A CRIME INVOLVING THE MISUSE OR THEFT OF MONEY?    YES    NO

 

AFFIDAVIT OF INDIVIDUAL

STATE OF

)

SS

COUNTY OF

)

, BEING DULY SWORN

DEPOSES AND SAYS THAT S/HE IS THE INDIVIDUAL WHO HAS MADE THE FOREGOING PROFESSIONAL SOLICITOR'S REGISTRATION STATEMENT, AS REQUIRED BY SECTION 8 OF "AN ACT TO REGULATE THE SOLICITATION AND COLLECTION OF FUNDS FOR CHARITABLE PURPOSES"; THAT S/HE HAS READ THE FOREGOING REGISTRATION STATEMENT AND KNOWS THE CONTENTS THEREOF; THAT S/HE IS AUTHORIZED TO VERIFY THIS REGISTRATION STATEMENT; THAT THE SAME IS TRUE TO HER/HIS OWN KNOWLEDGE; AND THAT THE STATEMENT WAS MADE FOR THE PURPOSE OF COMPLYING WITH THE REQUIREMENTS OF SECTION 8 OF SAID ACT.

Subscribed and sworn to before me,

this

day of

, 19

(Signature)

NOTARY PUBLIC

NOTE:

If sworn to outside the State of Illinois, a certificate of the County Clerk or other proper official, showing authority of the notary public or other official before whom the oath is administered, shall be attached.

AFFIDAVIT BY PROFESSIONAL FUND RAISER

STATE OF

)

SS

COUNTY OF

)

, BEING DULY SWORN

DEPOSES AND SAYS THAT S/HE IS THE (Title of Office)

OF THE (Name of Corporation)

OR MEMBER OF THE FIRMS OF (Partner or Association)

OR THE INDIVIDUAL WHO OR WHICH HAS or INTENDS TO EMPLOY THE FOREGOING PROFESSIONAL SOLICITATOR WHO IS REGISTERING, AS REQUIRED BY SECTION 8 OF "AN ACT TO REGULATE THE SOLICITATION AND COLLECTION OF FUNDS FOR CHARITABLE PURPOSES"; THAT S/HE HAS READ THE FOREGOING REGISTRATION STATEMENT AND KNOWS THE CONTENTS THEREOF; THAT S/HE IS AUTHORIZED TO VERIFY INFORMATION IN THIS REGISTRATION STATEMENT IS THE SAME AS IN THE EMPLOYMENT RECORDS OF THE PROFESSIONAL FUND RAISER; AND THAT THE STATEMENT WAS MADE FOR THE PURPOSE OF COMPLYING WITH THE REQUIREMENTS OF SECTION 8 OF SAID ACT.

Subscribed and sworn to before me,

this

day of

, 19

(Signature)

NOTARY PUBLIC

NOTE:

If sworn to outside the State of Illinois, a certificate of the County Clerk or other proper official, showing authority of the notary public or other official before whom the oath is administered, shall be attached.

 

(Source:  Added at 24 Ill. Reg. 14684, effective September 21, 2000)