Form Sa 1 – Fill Out and Use This PDF

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?

(B) Arises out of the conduct of solicitation of contributions for a charitable organization?

(C)Involves the larceny, theft, robbery, extortion, forgery, counterfeiting, fraudulent concealment, embezzlement fraudulent conversion, or misappropriation of funds?

(E) Involves assault or battery if such person proposes to be engaged in counseling, advising, housing, or sheltering of individuals?

(F) Pled guilty or nolo contendere (no contest) to any other felony offense?

7.Has any registration in any state ever been denied, revoked, suspended, or withdrawn?

8.Has Applicant ever been subject to any injunction or disciplinary proceeding by any state agency involving any aspect of fund raising or solicitation?

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?

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

Sworn to and subscribed before me this _________

Day of _________________________, 20_________

Notary Public ____________________________________________My Commission Expires: _______________________________

(Seal)

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. § 50-36-1:

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 non-immigrant under the Federal Immigration and Nationality Act 18 years of age or older with an alien number issued by the Department of Homeland Security or other federal immigration agency. Please submit a copy of your current immigration document(s) which includes either your Alien number or your I-94 number and, if needed, SEVIS number.

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________

My Commission Expires ______________________

(seal)

_____A Merchant Mariner Document or Merchant Mariner Credential issued by the United States Coast Guard

[O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

_____A Free and Secure Trade (FAST) card [O.C.G.A. § 50-36-2(b)(3); 22 CFR § 41.2]

_____A NEXUS card [O.C.G.A. § 50-36-2(b)(3); 22 CFR § 41.2]

_____A Secure Electronic Network for Travelers Rapid Inspection (SENTRI) card [O.C.G.A. §50-36-2(b)(3); 22 CFR

§ 41.2]

_____A driver’s license issued by a Canadian government authority [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]

_____A Certificate of Citizenship issued by the United States Department of Citizenship and Immigration

Services (USCIS) (Form N-560 or Form N-561) [O.C.G.A. § 50-36-2(b)(3); 6 CFR § 37.11]

_____A Certificate of Naturalization issued by the United States Department of Citizenship and Immigration

Services (USCIS) (Form N-550 or Form N-570) [O.C.G.A. § 50-36-2(b)(3); 6 CFR § 37.11]

_____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 50-36-2(c)]