PUBLIC SAFETY ORGANIZATION, INDEPENDENT PROMOTER, OR
PUBLIC SAFETY PUBLICATION SOLICITOR'S REGISTRATION STATEMENT
____New ____Renewal (Please print or type. Use additional sheets of paper if necessary.)
1. Name of solicitor:__________________________________________________________
Street Address:____________________________________________________________
City: ___________________________ State: ________ Zip: ____________
2. Mailing Address (if different from above):
_________________________________________________________________________
3. Telephone number: (______) _________________________
4. List below the name, street and mailing address, and telephone number of each public safety
organization, independent promoter, or public safety publication on whose behalf you solicit or will
solicit in this state.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
5. If the solicitor is not a resident of Texas, attach an irrevocable written consent form appointing the
secretary of state as agent for service of process on the solicitor for any action pertaining to a
violation of this act.
Executed this ____________ day of _____________________________, ____________.
(Signature)
__________________________________
(Printed Name & Title)
__________________________________
Form #3203
