Fillable Pursuant to Section 66-234 of the North Carolina (North Carolina Secretary of State)

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Pursuant to Section 66-234 of the North Carolina (North Carolina Secretary of State)

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Pursuant to Section 66-234 of the North Carolina General Statutes, the undersigned
submits the following information for the purpose of registering as a Membership
Camping Operator:
Type of Registration: Check the type of Registration below.
Initial Registration
$1500.00
Renewal Registration
$1000.00
If there isn’t room to complete the information required, attach the
information on a separate sheet.
Section I
1. Name of Applicant (complete one – Entity or Individual)
Business Entity Name of Applicant: _________________________________________
OR
Individual Name of Applicant: ______________________________________________
2. Principal Business Address:
Street or PO Box: ____________________________ City: _____________ State: _____
Zip Code: _______________ Telephone Number: _______________________________
3. Mailing Address (if different from principal business address shown above:
Street or PO Box: ____________________________ City: _____________ State: _____
Zip Code: _______________
4. Organizational Form of Business
Domestic Sole Proprietorship Foreign Sole Proprietorship
Domestic Corporation Foreign Corporation,
Domestic Nonprofit Corporation, Foreign Nonprofit Corporation,
Domestic Limited Liability Company Foreign Limited Liability Company
Domestic General Partnership Foreign General Partnership
Domestic Limited Partnership Foreign Limited Partnership
North Carolina Department of the Secretary of State
Application for Registration of Membership Camping
Operator
Business Services Division Special Programs Unit
PO Box 29622 Raleigh, NC 27626-0622
(10/28/2016) 2 | Page Form CG-01
Domestic Limited Liability Partnership Foreign Limited Liability
Partnership
5. The state or country under whose laws the entity was organized: ______________
6. The Date the entity was organized: _______________________
7. Offices
List the address of each of the entity’s offices in North Carolina. If you need additional
space, attach on a separate sheet.
8. Campground Address(es)
List the name and address of each campground located in North Carolina, which is
owned or operated, in whole or in part, by the applicant:
Section II
The name, address, and principal occupation for the past five (5) years of every officer of
the applicant, including its principal managers, and the extent and nature of the interest of
each person at the time the application is filed.
Please enter this information on a separate sheet and attach to this application.
Address
City
Zip
Name
Address
City State
Zip
NC
NC
NC
NC
Business Services Division Special Programs Unit
PO Box 29622 Raleigh, NC 27626-0622
(10/28/2016) 3 | Page Form CG-01
Section III
1. Is the company required to report under the Securities and Exchange Act of 1934?
Yes No
2. If No, provide a list of all owners of ten percent (10%) or more of the capital stock of
the applicant. Please enter this information on a separate sheet and attach to this
application
Section IV
1. Provide a brief description of and a certified copy of the instrument which creates the
applicant’s ownership of, or other right to use the campground and the facilities at the
campground which are to be available for use by purchasers.
2. Provide a brief description of any material encumbrances, together with a copy of any
lease, license, franchise, reciprocal agreement or other agreement entitling the applicant
to use such campground and facilities.
3. Provide any material provision of the agreement which restricts a purchaser’s use of
such campground or facilities.
Section V
1. Provide a sample copy of each instrument which will be delivered to a purchaser to
evidence his membership in the campground.
2. Provide a sample copy of each agreement which a purchaser will be required to
execute.
Section VI
Provide a list of special taxes or assessments, whether current or proposed, which affect
the campground.
Section VII
Provide a copy of the Disclosure Statement required by N.C.G.S. §66-238.
Section VIII
Provide a narrative description of the promotional plan for the sale of the membership
camping contracts.
Section IX
1. A statement of the relationship, if any, between the applicant and other parties owning,
controlling or managing the campground and the expected duration of that relationship.
Business Services Division Special Programs Unit
PO Box 29622 Raleigh, NC 27626-0622
(10/28/2016) 4 | Page Form CG-01
2. If the relationship is a contractual one, a statement of the methods and conditions
under which the relationship can be terminated prior to the expected termination of the
relationship.
Section X
Provide a complete list of locations and addresses of any and all sales offices located
within North Carolina.
Section XI
Provide the names of any other states or foreign countries in which an application for
registration of the membership camping operator or the membership camping contract or
any similar document has been filed.
Section XII
1. Provide a brief description of the membership camping operator’s experience in the
membership camping business, including the length of time such operator has been in the
membership camping business.
2. Provide a statement detailing whether the applicant within the past five years has been
convicted of any misdemeanor or felony involving the theft, fraud, dishonesty, or moral
turpitude.
3. Provide a statement detailing whether the applicant has been enjoined from, had any
civil penalty assessed for, or been found to have engaged in any violation of any law
designed to protect consumers.
If the applicant is a business entity, the statements above shall be provided for each
officer of the business entity.
Certification
The application is to be signed by the membership camping operator, an officer or
general partner thereof or by another person holding a power-of-attorney for this purpose
from the membership camping operator.
Applicant Signature: ____________________________________________
Printed Name: ____________________________________________
Title or Official Capacity: ____________________________________________
Date of Application: ____________________________________________
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Business Services Division Special Programs Unit
PO Box 29622 Raleigh, NC 27626-0622
(10/28/2016) 5 | Page Form CG-01
N
OTES:
1. T
his application must be submitted to the Department of the Secretary of State, Special Programs
Unit, P.O. Box 29622, Raleigh, NC 27626-0622 along with the filing fee.
2. Checks to be made payable to the “Secretary of State.”
3. T
his registration shall become effective upon the expiration of seven (7) business days followi
ng
i
ts filing with the Secretary of State. Filing is deemed to take place when the application is
stamped “Received.”
4. RENEWAL REQUIREMENT. Registration is effective for a period of one year. Registration
must be renewed annually prior to the expiration of the previous registration to insure continuity
of registration.
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Pursuant to Section 66-234 of the North Carolina (North Carolina Secretary of State)

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Completed 24 November 2020

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