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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]]