Form PFC-01

PROFESSIONAL FUNDRAISING CONSULTANT

– REGISTRATION STATEMENT –

Jim Ryan

Attorney General

PLEASE TYPE OR PRINT IN BLACK INK.  Respond to all items. If unable to answer in space provided attach a schedule in the same format.  Changes of or additions to the information in this statement are to be submitted in this format. All consultants must attach an affidavit attesting that the professional fund raising consultant has not or will not at any time have custody or control of charitable contributions.  Copies of all fund raising contracts must be submitted to this Office within ten (10) days of signing. If any of the information in this statement changes, this Office must be notified in writing within 10 days of the changes. All contracts between professional fund raising consultants and charitable organizations must be in writing and filed by the PFR with the Attorney General within ten (10) days of execution. Contracts shall contain the charity's legal name, their registration number, a street address, a contact party and that party's daytime telephone number. Changes or additions to the information in this statement must be submitted on this form.  One copy of this Registration Statement and attachments are to be filed with the Office of the Attorney General, Charitable Trust and Solicitations Bureau, 100 West Randolph Street, Chicago, Illinois 60601.

1.

THIS IS A (CHECK ONE and DATE):

NEW REGISTRATION (  )  REREGISTRATION (  )  CHANGE (  ) ADDITON (  ) AS OF  

      /        /     

2.

LEGAL NAME

REGISTRATION/REREGISTRATION

For Two (2) Years Upon Filing with the Attorney General

3.

MAIL ADDRESS

PFR NUMBER

11-

CITY, STATE, ZIP CODE

PHONE NUMBER

FEDERAL ID NUMBER

4.

TYPE OF FIRM (Individual, Partnership or Corporation)

5.

WHERE and WHEN ORGANIZED (Corporations must ATTACH Charter & Articles)

6.

NAME OF MANAGEMENT PERSON & PRESIDENT

TITLE

7.

A STREET ADDRESS (if different than above)

8.

NAME OF ILLINOIS REGISTERED AGENT

9.

AGENT'S MAIL ADDRESS (if P.O. BOX also a street address)

10.

GIVE PRINCIPAL ILLINOIS ADDRESS, IF ANY, AT WHICH RECORDS ARE KEPT AND NAME OF CUSTODIAN (NOT A P.O. BOX)

11.

LIST ALL BUSINESS LOCATIONS, OTHER THAN ABOVE, USED FOR FUNDRAISING.  (ATTACH SCHEDULE INDICATING ACTIVITY DESCRIPTION, STREET ADDRESS, CITY, STATE and if temporary location BEGINNING and ENDING USE DATES.)

12.

IF NAME IN ABOVE IS NOT THE CORPORATE or ONLY NAME USED BY THE REGISTRANT ATTACH SCHEDULE AND DOCUMENTS TO SUPPORT LEGAL USE OF OTHER NAMES (e.g., REGISTRATION UNDER THE ASSUMED NAME ACT)

13.

ILLINOIS SECRETARY OF STATE'S CORPORATE FILE NO.

IF A FOREIGN CORPORATION ATTACH A COPY OF AUTHORIZATION.

14.

LIST ALL PRINCIPAL PARTIES, OFFICERS, DIRECTORS, EXECUTIVE PERSONNEL, AND OWNERS OF TEN PERCENT OR MORE OF THE CAPITAL STOCK.  (ATTACH SCHEDULE IF NECESSARY)

NAME     STREET ADDRESS      TITLE     % OF INTEREST     BIRTH DATE     DRIVERS LICENSE #     STATE OF ISSUE

15.

LIST THE INTEREST OF ALL PRINCIPAL PARTIES, OFFICERS, DIRECTORS, EXECUTIVE PERSONNEL, OWNERS OF REGISTRANT AND THEIR FAMILY MEMBERS HAVING ANY OWNERSHIP INTEREST IN ANY OTHER FIRMS PROVIDING GOODS OR SERVICES USED IN FUNDRAISING

NATURE OF BUSINESS

NAME of PARTY

% INTEREST

NAME and STREET ADDRESS OF BUSINESS

16.

LIST THE INFORMATION REQUESTED BELOW FOR ALL CHARITABLE ORGANIZATIONS HAVING CONTRACTS WITH THIS FIRM FOR THE PERIOD OF THIS REGISTRATION OR CURRENTLY IN EFFECT INVOLVING THE RAISING OF FUNDS IN ILLINOIS AND ATTACH COPIES OF THE CONTRACTS.

ILLINOIS CO #

LEGAL NAME and STREET ADDRESS of CHARITABLE ORGANIZATION

FROM and TO DATES (Month/Day/Year)

17.

IS THE REGISTRANT LICENSED BY, REGISTERED WITH OR HAVE A PERMIT FROM ANY OTHER GOVERNMENTAL AGENCY FOR THE PURPOSE OF PROVIDING FUNDRAISING COUNSEL FOR CHARITABLE ORGANIZATIONS          YES         NO

IF "YES" LIST THE FOLLOWING INFORMATION:

NAME and ADDRESS of GOVERNMENTAL AGENCY

DATE of AUTHORIZATION (Month/Day/Year)

18.

HAS THE REGISTRANT EVER HAD ANY LICENSE, REGISTRATION OR PERMIT DENIED, CANCELED OR REVOKED, OR IS ANY SUCH ACTION PENDING?       YES       NO  IF "YES" ATTACH A SCHEDULE INDICATING NAME and ADDRESS of GOVERNMENTAL AGENCY, NATURE of ACTION, DATE of ACTION

19.

HAS ANY GOVERNMENTAL ACTION, OTHER THAN LISTED IN 20 ABOVE, BEEN TAKEN AGAINST THE BUSINESS OR ANY OF ITS PRINCIPAL PARTIES, EMPLOYEES, OFFICERS, DIRECTORS, EXECUTIVE PERSONNEL, OWNERS OF TEN PERCENT OR MORE OF THE CAPITAL STOCK OR THEIR RELATIONS IN CONNECTION WITH ANY FUNDRAISING ACTIVITY?        YES         NO

IF "YES" ATTACH A SCHEDULE INDICATING NAME and ADDRESS of GOVERNMENTAL AGENCY, AGAINST WHOM ACTION WAS TAKEN, NATURE of ACTION, DATE of ACTION.

20.

HAS ANY OF THE FIRM'S PRINCIPAL PARTIES, EMPLOYEES, OFFICERS, DIRECTORS, EXECUTIVE PERSONNEL, OWNERS OF TEN PERCENT OR MORE OF THE CAPITAL STOCK OR THEIR RELATIONS EVER BEEN CONVICTED OF A MISDEMEANOR INVOLVING THE MISAPPROPRIATION OR MISUSE OF MONEY OF ANOTHER, OR OF ANY FELONY?        YES        NO

IF "YES" ATTACH A SCHEDULE INDICATING NAME and ADDRESS of COURT, WHO WAS CONVICTED, NATURE of OFFENSE, DATE of CONVICTION.

NOTE:  VERIFICATION MUST BE BY THE CORPORATE PRESIDENT, A GENERAL PARTNER OR THE SOLE PROPRIETOR.

STATE OF

)

SS

AFFIDAVIT

COUNTY OF

)

I,

, under penalty of perjury and being sworn on oath state

(Name of PFC)

, that I have read the foregoing registration statement and personally

Subscribed and sworn to before me

this

day of

,

19

(Signature)

NOTARY PUBLIC