Public Solicitor Application FormBUSINESS NAME ____________________________________ REGISTRATION NO. _______________
APPLICATION FOR LICENSE FOR
PUBLIC SOLICITATION OF CONTRIBUTIONS
IN ACCORDANCE WITH ORD. 1976-57, AS AMENDED & ORD. 1987-60, AS AMENDED
COLLIER COUNTY, FLORIDA
1. (A) Name of Public Solicitor (PLEASE PRINT): ___________________________________________________________
(B) Purpose for which contributions are being solicited: _______________________________________________________
____________________________________________________________________________________________________
2. (A) Principal (& Mailing) Address and Phone #/Fax #: ________________________________________________________
____________________________________________________________________________________________________
(B) Local (& Mailing) Address and Phone #/Fax #: __________________________________________________________
____________________________________________________________________________________________________
3. Names and addresses of any Chapters, Branches or Affiliates in Collier County:
____________________________________________________________________________________________________
______________________________________________________________________________________ ______________
4. (A) Date public solicitor legally established: _______________________________________________________________
(Please attach copy of Department of State registration with business status update)
(B) Address at the time that solicitor was legally established: __________________________________________________
____________________________________________________________________________________________________
(C) Means by which solicitations will be made: _____________________________________________________________
(D) IF TAX-EXEMPT, state appropriate section of Internal Revenue Code and Tax-Exempt Number:
____________________________________________________________________________________________________
5. Names and addresses of Officers, Directors, Trustees and Principal Salaried Executive Staff Officers
(ATTACH A SEPARATE PAGE, if necessary):
Name Title Address City/State/Zip Phone/Fax
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
6. (A) Are you presently authorized by any governmental authority to solicit funds? (Y/N)______________________________
(B) IF YES, state the governmental authority & attach authorization: ____________________________________________
(C) Are you presently, or have you ever been enjoined by any court from so liciting funds? (Y/N) ______________________
(D) IF YES, state the circumstances, including the Case Number and Style: ______________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
7. State ALL PURPOSES for which contributions solicited SHALL BE USED: ____________________________________
____________________________________________________________________________________________________
8. Under WHAT NAME or NAMES will contributions be solicited? ______________________________________________
____________________________________________________________________________________________________
9. Names, Titles, Addresses & Phone/Fax Numbers of ALL INDIVIDUALS who will have FINAL RESPONSIBILITY
FOR and CUSTODY OF CONTRIBUTIONS:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
10. Names, Titles, Addresses & Phone/Fax Numbers of ALL INDIVIDUALS who will have RESPONSIBILTY FOR
FINAL DISTRIBUTION of CONTRIBUTIONS COLLECTED:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
11. Please furnish a FINANCIAL STATEMENT providing COMPLETE DISCLOSURE of ALL FISCAL ACTIVITIES for
PRIOR THREE (3) YEARS. Specifically, IDENTIFY THE AMOUNT OF FUNDS RAISED and give a breakdown of ALL
EXPENSES INCURRED in the DISBURSEMENT OF SAID SOLICITATIONS. This financial statement SHALL BE
VERIFIED UNDER OATH and ATTESTED TO BY THE CHIEF FISCAL OFFICER of the Public Solicitor.
Applicant (Signature): ___________________________________________________________
Printed Name: ___________________________________________________________
Street & Mailing Address: ________________________________________________________
Telephone/Fax/Email: ___________________________________________________________
Telephone # Fax # Email Address
State of _____________
County of _____________
The foregoing registration application was sworn to and subscribed before me on this ______ day of ___________, by
________________________________, who is personally known to me _________ (Y/N) or has produced _______________________ as
identification and who did take an oath.
BY: ____________________________________________
Deputy Clerk/Notary Public SEAL
------------------------------------------------------------------------------------------------------------------------------------------------------------------------
****This Registration Application shall be verified UNDER OATH and shall be accompanied by a five dollar ($5.00) Registration Fee
payable to the Clerk of the Circuit Court.
****Annually, on or before March 1st, a Statement showing the financial condition of the Public Solicitor as of the last day of the calendar
year, SHALL BE FILED with the Clerk of the Circuit Court. This Statement shall be VERIFIED and SWORN TO by a CPA or the Chief
Executive Officer of the Public Solicitor.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------
WILL THE APPLICANT BE REQUESTING TO CONDUCT IN-THE-ROAD CHARITABLE SOLICITATIONS?
CIRCLE (YES / NO) ; If YES:
PROCEED TO RIGHT-OF-WAY PERMITTING LOCATED AT: 2885 S. HORSESHOE DRIVE, NAPLES, FL
(additional application to the Transportation Department will apply)