CHARITABLE SOLICITORS PERMIT APPLICATION FEE: $0

Transcription

1 CITY OF BAYTOWN City Clerk s Office 2401 Market Street Baytown, Texas Phone: (281) Fax: (281) Web: FOR OFFICE USE ONLY Date Received: Date Processed: CHARITABLE SOLICITORS PERMIT APPLICATION FEE: $0 Charitable Organization Information 1) Name of Charitable Organization: 2) Address: City: State: Zip: 3) Describe the character and extent of the charitable, educational, patriotic, or philanthropic work done by the organization within the city during the preceding year: Primary Campaign Contact Information 1) Full Name of Primary Campaign Contact (This is the person who will be in charge of conducting the charitable solicitations campaign in the city): 2) Address: City: State: Zip: 3) Primary Phone Number: 4) Driver s License Number: State: 5) Date of Birth: 6) Have you ever been convicted of a misdemeanor involving moral turpitude or a felony?: NO YES Campaign Information 1) Describe the purpose of the campaign and specifically what the gross receipts derived from campaign will be used for: City of Baytown Charitable Solicitors Permit Application Page 1 of 4

2 Campaign Information (continued) 2) Describe the method(s) to be used in conducting the charitable solicitations campaign: 3) Will a professional promoter or professional solicitor be used?: NO YES 4) Campaign starting date: Ending date: 5) Please provide the estimated revenues and expenses expected from the charitable campaign: A. TOTAL AMOUNT TO BE COLLECTED: $ B. TOTAL AMOUNT TO BE SPENT FOR WAGES AND SALARIES: $ C. TOTAL AMOUNT TO BE SPENT ON FEES AND COMMISSIONS: $ D. ALL OTHER CAMPAIGN EXPENSES: $ E. TOTAL CAMPAIGN EXPENSES (Add Lines B,C,D): $ F. TOTAL AMOUNT GOING TO CHARITY (Subtract Line E from A) $ G. PERCENTAGE THAT WILL GO TO CHARITY (Divide Line F by A) % 6) Name of person responsible for the disbursement of funds raised during the campaign: Address: City: State: Zip: Primary Phone Number: Preceding Year Collection Information 1) Is the campaign as described in this application the same or substantially the same as a campaign from the preceding year?: NO YES If yes, please provide the following information from the preceding year s campaign: A. TOTAL AMOUNT COLLECTED: $ B. TOTAL FUNDRAISING EXPENSES: $ C. TOTAL AMOUNT TO CHARITY: $ D. PERCENTAGE THAT WENT TO CHARITY: % City of Baytown Charitable Solicitors Permit Application Page 2 of 4

3 Attachment Number Attachment Description Copy of charitable corporation s charter or articles of incorporation Proof of current status as an organization to which contributions are tax deductible for federal income purposes Copy of written agreement with professional promoter or professional solicitor Letters of authorization from all charities benefitting directly or indirectly from the charitable solicitation campaign Copy of financial statement of parent organization if funds are transmitted to parent organization for further disbursement Is the Required Documentation Attached to this Application? OR Not applicable OR Not applicable OR Not applicable OR Not applicable OR Not applicable 6 Signed background check authorization form 7 List of names and address of all officers and directors or trustees of the organization 8 List of names of all officers and directors or trustees present when the decisions were made regarding the purpose of the campaign and designation of the individual in charge of the disbursement of funds raised 9 Copy of Primary Campaign Contact s driver s license There are a few exceptions that, if applicable, may allow your organization to perform a charitable solicitor s campaign within the City without a permit. For more information please see Section of the City of Baytown Code of Ordinance or contact the City of Baytown City Clerk s office. Charitable solicitation permits are valid only for the period specified in the permit. Permits will be issued for a period of up to one year. A downloadable version of City of Baytown Code of Ordinances Chapter 74 Article III Charitable Solicitors is available on the City s website and can also be found at the following website: Should you have any questions, feel free to contact the City Clerk s office, Phone: (281) Fax: (281) Web: Application Attachments Other Important Information How can I submit this application? Mail or deliver original application to: City of Baytown, City Clerk, 2401 Market Street, Baytown, TX City of Baytown Charitable Solicitors Permit Application Page 3 of 4

4 Affidavit I, (Name of Applicant) do hereby state that all matters stated in this application and accompanying attachments are true and correct. I understand and have read Chapter 74, Article III of the Cod of Ordinances for the City of Baytown and understand that for any cause and/or reason I should fail to be in compliance, this permit may be revoked by an officer and/or other City of Baytown official. I further understand that neither myself or any agent or representative of this Organization shall at any time stand in a roadway in the city limits of Baytown to solicit a contribution or business from an occupant of a vehicle. I also attest that I am at least 18 years of age and have presented as evidence: State issued driver s license or I.D. card with a photograph, or information, including name, sex, date of birth; or A military identification card; or United States Passport. SIGNED on this the day of, 20. THE STATE OF COUNTY OF Signature Title SUBSCRIBED AND SWORN before me, this day of. (Seal) NOTARY PUBLIC STATE OF 12/26/12 LR/JTC City of Baytown Charitable Solicitors Permit Application Page 4 of 4

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