APPLICATION FOR SOLICITATION PERMIT (If spaces allowed are insufficient, attach additional sheets) |
1.) Name of Organization ____________________________________________________________ Address ________________________________________________________________________ Federal Tax Exempt Number # _____________________________________________________ |
2.) Name of Person Preparing Application _______________________________________________ Title or Relationship to Applicant _________________________________________________ Address _________________________________________________ Phone Number _________________________________________________ |
3.) If Applicant is not an individual, list name and addresses of principal Officers and Executives: Name ___________________________ Name ___________________________ Address _________________________ Address _________________________ ________________________________ ________________________________ |
Name ___________________________ Name ___________________________ Address _________________________ Address _________________________ ________________________________ ________________________________ |
4.) Names and addresses of Person or Persons by whom the receipts of such solicitation will be disbursed: Name ___________________________ Name ___________________________ Address _________________________ Address _________________________ ________________________________ ________________________________ |
5.) Describe purpose of solicitation: ____________________________________________________ ___________________________________________________________________________ Amount of Funds to be raised (estimate): $ ____________________________________________ Proposed use of disposition of funds raised: ___________________________________________ ___________________________________________________________________________ Will any funds raised by used in the Bremen Community: Yes ________ No ________ If Yes, to what extent? ____________________________________________________________ |
6.) Describe Method of Solicitation: ____________________________________________________ ___________________________________________________________________________ |
7.) Name and Address of Person in charge of solicitation: ________________________________________ ________________________________________ ________________________________________ |
8.) Names and Addresses of Persons actually involved in direct solicitation: __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ |
__________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ |
__________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ |
9.) Date and Hour of Commencement of Solicitation: _________________, 20_____ at ________:________ ___ M. |
10.) Date and Hour of Termination of Solicitation: _________________, 20_____ at ________:________ ___ M. |
11.) Estimated Cost of Solicitation: _____________________________________________________ Do any Solicitors receive compensation? Yes ________ No ________ If Yes, describe: _________________________________________________________________ |
12.) Attachments, to complete Application. Attach the following: a.) Specific Statement of need for funds being solicited. b.) Financial Statement for preceding fiscal year showing funds raised, expenses and distributions. c.) If not an individual, a certified copy of Resolution of Directors, authorizing the solicitation. |
The undersigned certifies that the foregoing information is true and accurate. Further, the undersigned also certifies that he is authorized to execute this Application on behalf of the Applicant. In addition, if there are any changes in the information furnished, the undersigned will promptly notify the Town prior to beginning solicitations. Any permit granted by the Town of Bremen will not be used or represented as an endorsement by the Town or any Officers of the Town of this organization or the solicitation. |
Applicant ________________________ ________________________ Dated By: __________________ |
(Prior Code, Ch. 43)