In the realm of charitable endeavors within Georgia, the Application for Registration as a Solicitor Agent, encapsulated in Form SA-1, stands as a crucial procedural step for individuals aiming to solicit charitable contributions legally. Overseen by the Securities and Business Regulation office under the guidance of Brian P. Kemp and Eric Lacefield, this process requires meticulous adherence to the stipulations set forth by the Georgia Charitable Solicitation Act of 1988 and its subsequent amendments. The form not only serves as a gateway for initial registration but also accommodates amendments and reinstatements, facilitating a spectrum of updates that reflect the dynamic nature of charitable solicitation activities. With a clear mandate that all agent registrations conclude on December 31 each year, the form underscores the importance of timely and complete submissions, accompanied by a financial remittance to the Secretary of State, to ensure uninterrupted authorization to solicit charitable contributions. Furthermore, the SA-1 delves into the applicant's criminal history, affiliations with paid solicitors or fundraising counsel, and the need for an unblemished record free of convictions related to fiscal malfeasance or violent crimes, thereby anchoring the integrity of solicitation activities. In essence, the SA-1 form embodies the regulatory framework that governs the ethical solicitation of charitable contributions in Georgia, emphasizing transparency, accountability, and the adherence to legal standards to protect both the solicitor and the generous public embarking on acts of philanthropy.
| Question | Answer |
|---|---|
| Form Name | Form Sa 1 |
| Form Length | 6 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 30 sec |
| Other names | SA1 237 coliseum drive macon ga securities and charities division form |
SECURITIES AND BUSINESS REGULATION
2 Martin Luther King, Jr. Drive, S.E.
Suite 802, West Tower
Atlanta, GA 30334
(404)
http://www.sos.state.ga.us/securities/
Brian P. Kemp |
Eric Lacefield |
|
Division Director |
||
Secretary of State |
||
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Application for Registration as a Solicitor Agent
Pursuant to The Georgia Charitable Solicitation Act of 1988, As Amended
□ Initial Registration - $ 50.00 |
□ Amendment - $15.00 |
□Reinstatement - $50.00 |
INSTRUCTIONS: THIS APPLICATION MUST BE COMPLETED AND FILED BEFORE SOLICITING CHARITABLE CONTRIBUTIONS. ALL AGENT REGISTRATIONS EXPIRE ON DECEMBER 31. ANSWER ALL QUESTIONS COMPLETELY, ATTACHING ADDITIONAL PAGES IF MORE SPACE IS NEEDED. CHECKS SHOULD BE MADE PAYABLE TO THE SECRETARY OF STATE. AMENDMENTS TO THIS REGISTRATION SHOULD BE FILED PROMPTLY, USING THIS FORM, TO REFLECT ANY CHANGES IN THE INFORMATION SUBMITTED.
1.(a) Full Name of Applicant: _____________________________________________________________________________________
(b)Home Address: ____________________________________________________________________________________________
(Address)
____________________________________________________________________________________________________________
(City) |
(State) |
(Zip) |
(Telephone No.) |
2.Address of Each Place of Business: _______________________________________________________________________________
(Address)
____________________________________________________________________________________________________________
(City) |
(State) |
(Zip) |
(Telephone No.) |
3.Identify the name(s) and address(s) of Paid Solicitor or Fundraising Counsel with which Agent will be affiliated. Indicate if affiliation is as an employee or as an independent contractor. Attach additional pages as needed.
□ Employee□ Independent Contractor
____________________________________________________________________________________________________________
Name of Paid Solicitor/Fundraising CounselSOS Registration No.
____________________________________________________________________________________________________________
(Address)
____________________________________________________________________________________________________________
(City)(State)(Zip)
____________________________________________________________________________________________________________
Contact Person |
Telephone No. |
4.If Applicant is an independent contractor, attach a copy of contract(s) indicated on #3.
5.Attach a list of all other sates in which Applicant is registered.
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6.In the past ten years has the applicant been convicted of or pled guilty or nolo contendere (no contest) to a felony or misdemeanor which:
(A)Involves the solicitation or acceptance of charitable contributions or the making of a false oath, the making of a false report, bribery, perjury, burglary, or conspiracy to commit any of the foregoing offenses?
□ Yes |
□ No |
(B) Arises out of the conduct of solicitation of contributions for a charitable organization?
□ Yes |
□ No |
(C)Involves the larceny, theft, robbery, extortion, forgery, counterfeiting, fraudulent concealment, embezzlement fraudulent conversion, or misappropriation of funds?
□
(D) Involves murder or rape?
□
Yes
Yes
□
□
No
No
(E) Involves assault or battery if such person proposes to be engaged in counseling, advising, housing, or sheltering of individuals?
□ Yes |
□ No |
(F) Pled guilty or nolo contendere (no contest) to any other felony offense?
□ Yes |
□ No |
7.Has any registration in any state ever been denied, revoked, suspended, or withdrawn?
□ Yes |
□ No |
8.Has Applicant ever been subject to any injunction or disciplinary proceeding by any state agency involving any aspect of fund raising or solicitation?
□ Yes |
□ No |
9.Has Applicant ever been subject to an order, consent order or any other disciplinary or administrative proceeding pursuant to the unfair and deceptive acts and practices law of any state?
□ Yes□ No
If the answer is “yes” to any of the aforementioned questions or if such proceeding is pending in any state, attach all pertinent information with respect to such injunction, disciplinary proceeding, conviction or charges.
If the applicant is seeking to be qualified to contact contributors and potential contributors in person, the applicant, by signing this application, gives the Office of the Secretary of State authorizes to conduct a criminal history background investigation.
10.Will applicant solicit contributions in person, as distinguished from mail, telephonic or electronic contact?
□ Yes |
□ No |
If the answer is “yes”, provide: |
|
Social Security Number: __________________________________ |
Date of Birth: ____________________________________ |
SOLICITOR AGENT CERTIFICATION
The undersigned applicant represents that the information and statements contained in this application, including the attached exhibits, are current, true and complete. The undersigned further represents that to the extent any information previously submitted is not amended, such information is currently accurate and complete. By signing this certification, the applicant certifies that he/she is at least 18 years of age and that willful misstatements or omissions of fact may result in administrative, civil or criminal action.
_________________________________________________________________
Print Name of Applicant
_________________________________________________________________ |
____________________________ |
Signature of Applicant |
Date |
Sworn to and subscribed before me this _________
Day of _________________________, 20_________
Notary Public ____________________________________________My Commission Expires: _______________________________
(Seal)
Form |
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AFFIDAVIT OF APPLICANT
I certify and declare that I am of good moral character and that all information contained in this application is true and correct, to the best of my knowledge. I understand that any willful omission or falsification of pertinent information required in the application is justification for the denial, suspension, or revocation of my registration by the Commission. I further swear and affirm that I have read and understand the current state laws and rules and regulations of the Georgia Paid Solicitor Agent Regulatory Commission and I agree to abide by these laws and rules, as amended from time to time.
By signing this application, electronically or otherwise, I hereby swear and affirm one of the following to be true and accurate pursuant to O.C.G.A. §
1) _______ I am a United States citizen 18 years of age or older. Please submit a copy of your current Secure
and Verifiable Document(s) such as driver’s license, passport, or document as indicated on pages 13 & 14 of this application.
2) _______ I am not a United States citizen, but I am a legal permanent resident of the United States 18 years of
age or older, or I am a qualified alien or
I also understand that if I have made a false statement on the application, or if I am found to have been convicted of a felony and have not had all of my civil rights restored pursuant to the law, the Commission may suspend my registration without a prior hearing. I shall be entitled to a hearing after the suspension of my registration.
I understand that I must maintain the records required by the Commission, and I shall make the records available for inspection by the Georgia Paid Solicitor Agent Regulatory Commission, or its authorized representative, at any time during normal business hours.
In making the above attestation, I understand that any failure to make full and accurate disclosures may result in disciplinary action by the Georgia Paid Solicitor Agent Regulatory Commission and/or criminal prosecution.
_____________________________________________________
Signature of ApplicantDate
_____________________________________________________
Print Applicant’s Name
Personally appeared before me, the undersigned official authorized to administer oaths, comes
_______________________________who deposes and swears that he/she is the person who executed this
(Applicant’s Name)
application for a license by examination for Paid Solicitor Agent in the State of Georgia; and that all of the statements
herein contained are true to the best of his/her knowledge and belief.
Sworn to and subscribed before me this ______ day of ___________________, 2________
Notary Public Signature ________________________________ |
________________________________ |
|
|
County |
State |
My Commission Expires ______________________
(seal)
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APPLICANT: PLEASE CHECK THE FORM OF IDENTIFICATION BELOW THAT YOU POSSESS. RETURN THIS FORM ALONG WITH A COPY OF YOUR APPROPRIATE DOCUMENTATION.
________________________________________
Name
Secure and Verifiable Documents Under O.C.G.A. §
Issued August 1, 2011 by the Office of the Attorney General, Georgia
The Illegal Immigration Reform and Enforcement Act of 2011 (“IIREA”) provides that “[n]ot later than August 1, 2011, the Attorney General shall provide and make public on the Department of Law’s website a
list of acceptable secure and verifiable documents. The list shall be reviewed and updated annually by the Attorney General.” O.C.G.A. §
basis, if necessary.
The following list of secure and verifiable documents, published under the authority of O.C.G.A. §
_____ A United States passport or passport card [O.C.G.A. §
_____A United States military identification card [O.C.G.A. §
_____A driver’s license issued by one of the United States, the District of Columbia, the
Commonwealth of Puerto Rico, Guam, the Commonwealth of the Northern Marianas Islands, the United States Virgin Island, American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer [O.C.G.A. §
_____An identification card issued by one of the United States, the District of Columbia, the Commonwealth of Puerto
Rico, Guam, the Commonwealth of the Northern Marianas Islands, the United States Virgin Island, American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer [O.C.G.A. §
_____A tribal identification card of a federally recognized Native American tribe, provided that it contains a
photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer. A listing of federally recognized Native American tribes may be found at: http://www.bia.gov/WhoWeAre/BIA/OIS/TribalGovernmentServices/TribalDirectory/index.htm [O.C.G.A. §
_____A United States Permanent Resident Card or Alien Registration Receipt Card [O.C.G.A. §
CFR § 274a.2]
_____An Employment Authorization Document that contains a photograph of the bearer [O.C.G.A. §
CFR § 274a.2]
_____A passport issued by a foreign government [O.C.G.A. §
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_____A Merchant Mariner Document or Merchant Mariner Credential issued by the United States Coast Guard
[O.C.G.A. §
_____A Free and Secure Trade (FAST) card [O.C.G.A. §
_____A NEXUS card [O.C.G.A. §
_____A Secure Electronic Network for Travelers Rapid Inspection (SENTRI) card [O.C.G.A.
§ 41.2]
_____A driver’s license issued by a Canadian government authority [O.C.G.A. §
_____A Certificate of Citizenship issued by the United States Department of Citizenship and Immigration
Services (USCIS) (Form
_____A Certificate of Naturalization issued by the United States Department of Citizenship and Immigration
Services (USCIS) (Form
_____In addition to the documents listed herein, if, in administering a public benefit or program, an agency is required
by federal law to accept a document or other form of identification for proof of or documentation of identity, that document or other form of identification will be deemed a secure and verifiable document solely for that particular program or administration of that particular public benefit. [O.C.G.A. § secure and
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