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TELEPHONIC SELLER REGISTRATION AND BOND REQUIREMENT (North Carolina Secretary of State)

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BUSINESS SERVICES DIVISION PO BOX 29622 RALEIGH, NC 28626-0622
November, 2016 (Form TS-01)
State of North Carolina
Department of the Secretary of State
TELEPHONIC SELLER REGISTRATION AND BOND
REQUIREMENT
This packet contains information on North Carolina Registration and Bonding Requirement Act
in Chapter 66, Article 33 of the North Carolina General Statutes.
You are invited to examine carefully the sections of the Act dealing with the definition of
“telephonic seller” and the exemptions to determine if you need to register as a telephone seller.
If your firm meets the definition of “telephonic seller” and does not fall within one of the
exemptions cited in NCGS 66-260 (11) it must register with the North Carolina Department of
the Secretary of State.
The annual filing fee is $100.00. Checks should be made payable to the NC Secretary of
State.
Completed applications should be sent to:
Telephonic Seller Registration
Attention: Wendy Haynes
North Carolina Department of the Secretary of State
P.O. Box 29626
Raleigh, NC 27626-0626
BUSINESS SERVICES DIVISION PO BOX 29622 RALEIGH, NC 28626-0622
November, 2016 (Form TS-01)
TELEPHONIC SELLER
REGISTRATION FORM
1. Registrant’s Name(s): ____________________________________________________
_______________________________________________________________________
(List all names, including any assumed names under which the telephonic seller intends to do
business in North Carolina.)
2. Organizational Form of Business
Domestic Sole Proprietorship Foreign Sole Proprietorship
Domestic Corporation Foreign Corporation
Domestic Nonprofit Corporation, Foreign Nonprofit Corporati on
Domestic Limited Liability Company Foreign Limited Liability Company
Domesti c General Partnership Forei gn General Partnershi p
Domesti c L i mi ted Partnershi p Foreign Limited Partnership
Domestic Limited Liability Partnership Foreign Limited Liability Partnership
If the seller is a corporation, attach a copy of its Articles of Incorporation, By-laws, and
amendments.
If the seller is a partnership, attach a copy of the partnership agreement.
3. List the registrant’s principal place of business (Note: private mail service addresses
are not acceptable in response to this item):
Street Address: _____________________________________ Suite/Apt: ____________
City: __
____________________ State/Province: ________________________________
Zip: _________________ Country: __________________________________________
4. Provide the complete street addresses of each location from which telephonic sales are to be
made, together with all telephone numbers with area codes serving each address.
Address 1: _________________________________________ Suite/Apt: ____________
City: ______________________ State/Province: _________________________________
Zip: _______________________ Country: _____________________________________
BUSINESS SERVICES DIVISION PO BOX 29622 RALEIGH, NC 28626-0622
November, 2016 (Form TS-01)
Ph. No. 1:____________________________________________________________
Ph. No. 2: _____________________________________________________________
Ph. No. 3:____________________________________________________________
Ph. No. 4: _____________________________________________________________
Ph. No. 5:____________________________________________________________
Ph. No. 6: _____________________________________________________________
Address 2: _________________________________________ Suite/Apt: ____________
City: ______________________ State/Province: _________________________________
Zip: _______________________ Country: _____________________________________
Ph. No. 1:____________________________________________________________
Ph. No. 2 _____________________________________________________________
Ph. No. 3:____________________________________________________________
Ph. No. 4: _____________________________________________________________
Ph. No. 5:____________________________________________________________
Ph. No. 6: _____________________________________________________________
Address 3: _________________________________________ Suite/Apt: ____________
City: ______________________ State/Province: _________________________________
Zip: _______________________ Country: _____________________________________
Ph. No. 1:____________________________________________________________
Ph. No. 2: _____________________________________________________________
Ph. No. 3:____________________________________________________________
Ph. No. 4: _____________________________________________________________
Ph. No. 5:____________________________________________________________
Ph. No. 6: _____________________________________________________________
Address 4: _________________________________________ Suite/Apt: ____________
City: ______________________ State/Province: _________________________________
Zip: _______________________ Country: _____________________________________
Ph. No. 1:____________________________________________________________
Ph. No. 2: _____________________________________________________________
Ph. No. 3:____________________________________________________________
Ph. No. 4: _____________________________________________________________
Ph. No. 5:____________________________________________________________
Ph. No. 6: _____________________________________________________________
If there are other locations and/or telephone numbers, please note the use of an attachment on the
application form and submit the numbers and/or addresses on a separate sheet.
BUSINESS SERVICES DIVISION PO BOX 29622 RALEIGH, NC 28626-0622
November, 2016 (Form TS-01)
5. Please complete the following for each principal:
Principal 1 Name: ______________________________ Title: ________________________
Residential Address: _________________________________City: ____________________
State/Province: ________________ Zip: ________________ Country: __________________
Date of Birth: _________________________ SSN: _________________________________
Principal 2 Name: ______________________________ Title: ________________________
Residential Address: _________________________________City: ____________________
State/Province: ________________ Zip: ________________ Country: __________________
Date of Birth: _________________________ SSN: _________________________________
Principal 3 Name: ______________________________ Title: ________________________
Residential Address: _________________________________City: ____________________
State/Province: ________________ Zip: ________________ Country: __________________
Date of Birth: _________________________ SSN: _________________________________
Principal 4 Name: ______________________________ Title: ________________________
Residential Address: _________________________________City: ____________________
State/Province: ________________ Zip: ________________ Country: __________________
Date of Birth: _________________________ SSN: _________________________________
If there are other principals please note the use of an attachment on the application form and
submit the information on a separate sheet.
BUSINESS SERVICES DIVISION PO BOX 29622 RALEIGH, NC 28626-0622
November, 2016 (Form TS-01)
6. Please list the true name, street address, date of birth, and social security number for
each operator, together with the operator’s full employment history during the
preceding two years.
Operator 1 Name: ______________________________ Title: ________________________
Residential Address: _________________________________City: ____________________
State/Province: ________________ Zip: ________________ Country: __________________
Date of Birth: _________________________ SSN: _________________________________
Operator 1 Employment History
Employer’s Name and Street Address Employment Dates
______________________________ From __________to_________
______________________________
______________________________
______________________________
______________________________ From __________to__________
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BUSINESS SERVICES DIVISION PO BOX 29622 RALEIGH, NC 28626-0622
November, 2016 (Form TS-01)
Operator 2 Name: ___________________________________________________________
Residential Address: _________________________________City: ____________________
State/Province: ________________ Zip: ________________ Country: __________________
Date of Birth: _________________________ SSN: _________________________________
Operator 2 Employment History
Employer’s Name and Street Address Employment Dates
______________________________ From __________to_________
______________________________
______________________________
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______________________________ From __________to__________
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BUSINESS SERVICES DIVISION PO BOX 29622 RALEIGH, NC 28626-0622
November, 2016 (Form TS-01)
Operator 3 Name: ___________________________________________________________
Residential Address: _________________________________City: ____________________
State/Province: ________________ Zip: ________________ Country: __________________
Date of Birth: _________________________ SSN: _________________________________
Operator 3 Employment History
Employer’s Name and Street Address Employment Dates
______________________________ From __________to_________
______________________________
______________________________
______________________________
______________________________ From __________to__________
______________________________
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BUSINESS SERVICES DIVISION PO BOX 29622 RALEIGH, NC 28626-0622
November, 2016 (Form TS-01)
Operator 4 Name: ___________________________________________________________
Residential Address: _________________________________City: ____________________
State/Province: ________________ Zip: ________________ Country: __________________
Date of Birth: _________________________ SSN: _________________________________
Operator 4 Employment History
Employer’s Name and Street Address Employment Dates
______________________________ From __________to_________
______________________________
______________________________
______________________________
______________________________ From __________to__________
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______________________________ From __________to____________
______________________________
______________________________
______________________________
BUSINESS SERVICES DIVISION PO BOX 29622 RALEIGH, NC 28626-0622
November, 2016 (Form TS-01)
Operator 5 Name: ___________________________________________________________
Residential Address: _________________________________City: ____________________
State/Province: ________________ Zip: ________________ Country: __________________
Date of Birth: _________________________ SSN: _________________________________
Operator 5 Employment History
Employer’s Name and Street Address Employment Dates
______________________________ From __________to_________
______________________________
______________________________
______________________________
______________________________ From __________to__________
______________________________
______________________________
______________________________
______________________________ From __________to___________
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______________________________ From __________to____________
______________________________
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______________________________
______________________________ From __________to____________
______________________________
______________________________
______________________________
If there are other operators, please note the use of an attachment on the application form and
submit the information on a separate sheet.
BUSINESS SERVICES DIVISION PO BOX 29622 RALEIGH, NC 28626-0622
November, 2016 (Form TS-01)
7. List the name and address of all banks or savings institutions where the telephonic seller
maintains deposit accounts.
Bank 1 Name: ______________________________________________________________
Address: __________________________________________City: ____________________
State/Province: ________________ Zip: ________________ Country: __________________
Bank 2 Name: ______________________________________________________________
Address: __________________________________________City: ____________________
State/Province: ________________ Zip: ________________ Country: __________________
Bank 3 Name: ______________________________________________________________
Address: __________________________________________City: ____________________
State/Province: ________________ Zip: ________________ Country: __________________
Bank 4 Name: ______________________________________________________________
Address: __________________________________________City: ____________________
State/Province: ________________ Zip: ________________ Country: __________________
If there are other banking institutions, note the use of an attachment on the application form and
submit the information on a separate sheet.
8. List the name and address of each long-distance telephone carrier used by the telephonic
seller.
Telephone Carrier 1 Name: ____________________________________________________
Address: __________________________________________City: ____________________
State/Province: ________________ Zip: ________________ Country: __________________
BUSINESS SERVICES DIVISION PO BOX 29622 RALEIGH, NC 28626-0622
November, 2016 (Form TS-01)
Telephone Carrier 2 Name: ____________________________________________________
Address: __________________________________________City: ____________________
State/Province: ________________ Zip: ________________ Country: __________________
Telephone Carrier 3 Name: ____________________________________________________
Address: __________________________________________City: ____________________
State/Province: ________________ Zip: ________________ Country: __________________
If there are other long-distance telephone carriers, note the use of an attachment on the
application form and submit the information on a separate sheet.
9. Provide a summary on an attachment of each civil or criminal proceeding brought
against the telephonic seller, any of its principals, or any of its room operators during
the preceding five (5) years by federal, state or local officials relating to telephonic sales
practices of each.
The summary shall include the date each action was commenced, the criminal or civil charges
alleged, the case caption, the court file number, the court venue, and the disposition of the
action.
BUSINESS SERVICES DIVISION PO BOX 29622 RALEIGH, NC 28626-0622
November, 2016 (Form TS-01)
SIGNATURES AND CERTIFICATION OF PRINCIPALS
SUBMITTING REGISTRATION
The undersigned hereby certify that they are principals for ______________________
__________________________________ (Registrant); that, following due diligence, they
submit the foregoing information on behalf of registrant; that based upon said due and diligent
efforts and their personal knowledge the information submitted as part of this registration is
complete and accurate; and that they understand North Carolina General Statute § 66-261(d)
requires them to file an Addendum to this registration reflecting any changes in or additions to
the foregoing information within ten days after the occurrence of events giving rise to such
changes.
Principal #1 ________________________________
Title _____________________________________
Principal #2 ________________________________
Title _____________________________________
Principal #3 ________________________________
Title _____________________________________
Principal #4 ________________________________
Title _____________________________________
If there are more than four (4) principals, add their signatures and titles below or on a separate sheet
with a notary acknowledgement.
BUSINESS SERVICES DIVISION PO BOX 29622 RALEIGH, NC 28626-0622
November, 2016 (Form TS-01)
STATE OF _____________________ )
) S. S.
COUNTY OF ___________________ )
I, ________________________________, a Notary Public for said County and State, do
hereby certify that _______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
personally appeared before me this day and acknowledged the due execution of the foregoing
instrument .
Witness my hand and official seal, this the _______ day of _______________, 20_____.
(Official Seal) ____________________________________
NOTARY PUBLIC
My commission expires _______________________, 20___
(Separate Notary Acknowledgment where certain principals cannot execute Registration at the same
time or place as the others.)
STATE OF ____________________ )
) S. S.
COUNTY OF __________________ )
I, ________________________________, a Notary Public for said County and State, do
hereby certify that _______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
personally appeared before me this day and acknowledged the due execution of the foregoing
instrument.
Witness my hand and official seal, this the ______ day of __________________, 20 _____
(Official Seal) __________________________________
NOTARY PUBLIC
My commission expires ____________________, 20____.
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TELEPHONIC SELLER REGISTRATION AND BOND REQUIREMENT (North Carolina Secretary of State)

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