Fillable Telemarketing Registration Application (Information Technology Section)

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Telemarketing Registration Application (Information Technology Section)

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The Telemarketing Registration Application (Information Technology Section) form is 4 pages long and contains:

  • 1 signature
  • 24 check-boxes
  • 141 other fields

Country of origin: US
File type: PDF

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Page 1 of 4
COMMONWEALTH OF PENNSYLVANIA
OFFICE OF ATTORNEY GENERAL
Bureau of Consumer Protection
15th Floor Strawberry Square
Harrisburg, PA 17120
Phone: (717) 783-1992
http://www.attorneygeneral.gov
Telemarketing Registration Application
PART I:
Identification
Name of
Telemarketer
Location of
Telemarketer
(Preferred mailing address for notices?
Yes
No)
City
State
Zip Code
County
Name of C
orporation,
LLC,
Partnership or Individual Owner
Address
(
Preferred mailing address for notices?
Yes
No)
City
State
Zip Code
County
Name of Contact Person
Fax Number
Telephone Number
Email
Address
Name &
Addresses
of Registered Agent (If Owner is located outside of PA)
Current Registration Number (if
applicable)
This Form is (check one):
A registration for a new telemarketing entity not previously registered in PA
A change to the registered telemarketer’s ownership or address information
A change to a different Bond or Letter of Credit for a registered telemarketer
Other (please indicate):
Please submit the original copy of the bond or letter of credit.
Location(s) of Call Centers for calls placed to PA residents
Name
Address
–
Line 1
Address
–
Line 2
City
State
Zip Code
Name
Address
–
Line 1
Address
–
Line 2
City
State
Zip Code
Name
Address
–
Line 1
Address
–
Line 2
City
State
Zip Code
Page 2 of 4
PART II: Telemarketing Campaign
On whose behalf will the telemarketing entity make calls into Pennsylvania?
What name and number will be displayed on the consumer’s caller id?
List the names of all telemarketers currently employed by the telemarketing entity.
(Attach additional sheets, if necessary.)
Name
Title
Home Address
City
State
Zip Code
Name
Title
Home Address
City
State
Zip Code
Name
Title
Home Address
City
State
Zip Code
Name
Title
Home Address
City
State
Zip Code
Name
Title
Home Address
City
State
Zip Code
Name
Title
Home Address
City
State
Zip Code
Name
Title
Home Address
City
State
Zip Code
Page 3 of 4
PART I
I
I:
Ownership Information
1. The Telemarketer identified in paragraph 1 above is a: (check one)
Corporation. State of registration: Pennsylvania Other: ______
Date of incorporation: ________________________
If not a PA Corporation, have you obtained a certificate of authority to do
business in Pennsylvania? Yes No
Have you filed a Fictitious Name Statement with the Department of State?
Yes No
Limited Liability Company (LLC). Date of formation: _____________________
State of formation: Pennsylvania Other: ________________
If not a PA LLC, have you obtained a certificate of authority to do business in
Pennsylvania? Yes No
Have you filed a Fictitious Name Statement with the Department of State?
Yes No
Sole Proprietorship. Have you filed a Fictitious Name Statement with the
Department of State? Yes No
Partnership. Have you filed a Fictitious Name Statement with the Department of
State? Yes No
Other. Please specify type of business and state the form of business which
operates the telemarketing entity:
2. Please state the names, titles and business addresses of all officers and directors of
a corporation; members and managers of an LLC; general partners of a partnership; or
in the case of a sole proprietorship, any person with an ownership interest in the
telemarketing entity. (Attach additional sheets if necessary):
Name
Title
Percentage of ownership
Home
Address
City
State
Zip Code
Name
Title
Percentage of ownership
Home
Address
City
State
Zip Code
Name
Title
Percentage of ownership
Home Address
City
State
Zip Code
Name
Title
Percentage of ownership
Home
Address
City
State
Zip Code
Page 4 of 4
PART IV: Financial Security Information
1. The telemarketing entity has satisfied the financial security requirement of the
Telemarketer Registration Act as follows (check one, and complete the blanks):
Obtained surety bond in the amount of $50,000.00 from
________________________________. Include the original surety bond with
this application.
Name of Contact Person at the Financial Institution
Telephone number
Obtained a Certificate of Deposit in the amount of $50,000.00 from
_______________________________. Include the certificate of deposit with
this application.
Name of Contact Person at the Financial Institution
Telephone number
Enclosed a check in the amount of $50,000.00 made payable to the Office of
Attorney General to be held on deposit.
PART V: Certifications
Please check the boxes to indicate that you have read and understand the requirements.
I understand that the telemarketing entity identified in paragraph 1 must comply with
the Do Not Call list requirements contained in the Telemarketer Registration Act.
I understand that my registration is valid for two years from the date of issuance and
that I must re-register prior to its expiration.
I have enclosed a cashier’s check, certified check or money order made payable to
the Office of Attorney General to satisfy the $500.00 application fee requirement.
I understand that I am under a continuing obligation to notify the Bureau of
Consumer Protection in writing of any change in the information provided in this
registration application within 14 days.
I hereby certify that the information contained in the Registration Application is true and
correct. I further certify that I have actual authority to make this certification on behalf of
the Telemarketing Entity identified in paragraph 1. I also understand that any false
statements made herein are subject to the penalties for unsworn falsification to
authorities pursuant to 18 Pa. C.S. Section 4904.
Signature of Authorized Party: Date:
Print Name: Title:
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Telemarketing Registration Application (Information Technology Section)

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Completed 21 May 2022

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