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OFFICE OF THE SECRETARY OF STATE
VETERANS ORGANIZATION SOLICITOR'S REGISTRATION STATEMENT
_____New _____Renewal (Please print or type. Use additional sheets of paper if necessary)
1. Name of solicitor:________________________________________________________________
Type of organization: (Corporation, unincorporated entity, partnership, etc.) ____________
Mailing Address: _______________________________________________________________
Telephone Number: (__________) __________________________
2. Give the name, address, and telephone number of each veterans organization on whose
behalf you solicit or will solicit.
3. List all the other states in which you are registered as a solicitor and the status of those
registrations.
4. Number of counties in which you solicit. _________________________
5. Have you, as a solicitor, ever forfeited a bond under this Act? ____________________
If so, how many? _____________________________ What was (were) the date(s) of
forfeiture? _________________________________________________________________
Executed this ______________ day of ___________________________, ___________.
(Signature) (Printed or Typed Name & Title)