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No.[[blank line]]

TO BE FILLED IN BY SOLICITORS OF CASH DONATIONS OR ADVERTISING IN PROGRAMS OR PERIODICALS PUBLISHED FOR CHARITABLE ENTERPRISES OR BENEVOLENT OR TRADE ORGANISATIONS

This request is for: (Please answer by checking)

An Advertisement [[blank line]] 
A Cash Donation [[blank line]]
A Subscription [[blank line]]
Purchase of Tickets [[blank line]]
Name of Organization (State if and where incorporated) [[blank line]]
Address [[blank line]]
Name and Address of Chief Executive [[blank line]]
Name of Publication or Performance [[blank line]]
Solicitor's Name and Address  [[blank line]]
Position in Organization [[blank line]]
On Salary or Commission [[blank line]]
Percent commission rec'd. [[blank line]]%
Amount requested of us $ [[blank line]] Circulation of publication or
Attendance at performance [[blank line]]
How can we verify the above [[blank line]]
Periodical or one-time request [[blank line]] How often [[blank line]]
Paid Circulation [[blank line]] Free Circulation [[blank line]] Price per copy or per ticket $ [[blank line]] Name and address of Printer
[[blank line]]
Date of Appearance [[blank line]] Closing Date [[blank line]]
Send copy to [[blank line]] Make payment to [[blank line]]

Has your organization submitted above facts to:
(1) New York Better Business Bureau? [[blank line]]
(2) Bureau of Advice & Information of Charity Organization Society? [[blank line]]
(3) Department of Public Welfare, City of New York? [[blank line]]

I hereby certify that the above statements are true

NAME [[blank line]]
TITLE [[blank line]]