Date of Application:_______________________
Date Permit Begins:_______________________
Date Permit Expires:______________________
Please complete the following information:
Name of organization applying for permit to solicit funds within the Corporate limits of
the City of High Point, under Title 11, Chapter 5, Article B, Sections 11-5-21 through 11-
5-28 of the Code of Ordinances of the City of High Point, Revised 1982:
It is understood and agreed that any permit issued pursuant to this application, is issued
on condition that the answers to the following questions are true and correct to the best of
the knowledge, information and belief of the applicant. Failure to provide true and
accurate information on this application will result in revocation or denial of permit.
1. Has your organization applied for and received a license from the North Carolina
Department of Human Resources, Division of Facility Services to solicit in North
Carolina? YES__________ NO__________
Is your organization licensed as “professional solicitors”?
YES__________ NO__________
If YES, copy must be attached to application.
2. Name & Address of the organization applying for a permit to solicit:
3. Names and addresses of its principal officers and management:
4. The purpose for which any receipts derived from such solicitations are to be used:
5. The name and address of the person or persons who will be in direct charge of
Conducting the solicitations:
6. The name of the person or persons by whom the receipts of such solicitations shall
be disbursed:
7. Give an outline of the method or methods to be used in conducting solicitations
Telephone, door-to-door, etc… (attach schedule if necessary):
8. The time when such solicitations shall be made, giving the proposed dates for the
beginning and ending of such solicitation, not to exceed three (3) months:
9. The amount of wages, fees, commissions, expenses or emoluments to be expended
or paid to anyone in connection with such solicitation, together with the manner in
which such wages, fees, expenses, commissions or emoluments are to be
expended, to whom paid, and the amount thereof (attach schedule if necessary):
10. Have you or your associates solicited during the past two (2) years within the
Corporate Limits of the City of High Point? YES_________ NO__________
Name of organization your represented?_________________________________
11. Attach a financial statement for the last preceding fiscal year of any funds
collected for the purpose set out in Section 3 hereof, by the organization or persons
seeking a permit for such solicitation, said statement shall give the amount of
money so raised, together with the cost of raising it, and the final distribution
12. Attach a full statement of the character and extent of the charitable, religious,
Educational or philanthropic work being done by the applicant organization
within the City of High Point.
13. Provide such other information as may be requested by the City Clerk in order
to fully determine the kind and character and the worthiness of the proposed
solicitation, and as to whether or not such solicitation is in the interest of
protecting the health, life and property of the Citizens of this City; and, in the
interest of preserving and enforcing good government; and, for the security of the
City of High Point, and its citizens:
A. Has anyone other than a member of your organization been employed
to solicit on behalf of the organization you represent?
YES__________ NO__________
If YES, copy of receipt for $10.00 fee paid pursuant to Title 11,
Section 11-5-23 issued by the City Collector, must be attached to this
B. Name and address of person or organization employed to solicit on
behalf of your organization:_________________________________
C. What percentage of the amount collected will your organization
receive from said solicitation, pursuant to contract or agreement?
14. Provide a complete list of names of solicitors and representatives with addresses
(may be attached separately, or written in on the back of this application).
Applicant’s Signature
Printed Name
Contact Numbers (phone, fax)
e-mail address
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Subscribed to an sworn before me,
This the ______ day of _____________________, 20______.
Notary Public
My commission expires:_________________
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