POLICE DEPARMENT
464 N Rexford Drive
Beverly Hills,
CA 90210-4817
                                      DAVID L. SNOWDEN
Chief of Police
310.285.2102
310.246.9854 (FAX)
  CITY OF BEVERLY HILLS

CHARITABLE SOLICITATIONS COMMISSION

REQUEST FOR PERMIT TO SOLICIT
 
     
 This application for request to solicit in the City of Beverly Hills is submitted pursuant to Beverly Hills Municipal Code Section 4-3.804.

A. Application Information
 
  Name of Organization :
  Federal EIN/TIN :
  Address :
  City, Zip :
  Telephone :
  Fax :
  Email :
Name of person to contact in the event there are questions concerning this applications:
 

Name

Telephone

Email

 B-1. Are you a 501 (c)(3) organization?
 
If yes, please submit a copy of the letter your organization received from the IRS recognizing your tax-exempt status.  This is a one-time only request for as long as your file remains active with the City of Beverly Hills. 


B-2. Please indicate the last year you filed Form 990 or Form 990-EZ with the Internal Revenue Service:



Check the name of the form filed:



If Form 990 was filed, please provide the amounts found on the Statement of Functional Expenses (Page 10):
 
Line 25, Column A (Total Expenses):

Line 25, Column B (Program Service Expenses):

 
If neither Form 990 nor Form 990-EZ filed, please explain or indicate the reason for exemption:


B-3. Are you registered with the State of California's Registry of Charitable Trusts?

If yes, please enter the registration Number : .

If yes, please submit a copy of the letter your most recent Registry of Charitable Trusts Registration/Renewal Fee Report.  (Please upload a copy of your document(s) here.  If you cannot upload your document(s), you may fax it with the signature page of your applications.) 
 

C. What is the purpose of this solicitation?


D. Please estimate the following:
  Total amount of funds (Gross) proposed to be raised during this solicitation $
  Cost (Expense) of this proposed solicitation $
  NOTE: The commission's practice is to publicize charities that have repeatedly recorded net proceeds of less than 50% of total receipts from fundraising events.

E. Previous fund-raising event :
  Gross : $
  Expense : $
  Please attach a copy of the financial statement of your previous fund-raising event.
   
  (If you do not have a document to upload, you may fax it it with the signature page of your application.)


F. Names of Beneficiaries from this solicitation:
  1)
  2)
  3)


G. Name and address of the person or persons who will disburse the receipts of this solicitation:
  1) Name 2)
  1) Address 2)
  1) City, Zip 2)
 
 
  H. Name and address of the person or persons who will be in direct charge of conducting the solicitation:
  1) Name 2)
  1) Address 2)
  1) City, Zip 2)
 
 
  I. Name and address of all promoters connected to or to be connected with the proposed solicitation:
  1) Name 2)
  1) Address 2)
  1) City, Zip 2)


J. Please list the method(s) to be used in conducting the solicitation (e.g., mail, phone or personal contact):

 
 

  K. List the name and address of any individual who to receive, directly or indirectly, any WAGES, FEES, COMMISSIONS, EXPENSE OR EMOLUMENTS:
  1) Name 2)
  1) Address 2)
  1) City, Zip 2)
  Attach additional sheets if necessary.    
 
 
  L. What is the amount of such wages, fees, commissions, expenses or emoluments for the individual(s) listed under item "L"?
  1) $ 2) $
  If the permit to solicit is approved, any individuals listed under item "L" must comply with additional requirements established in the Beverly Hills Municipal Code.


M. Event Category

  Monetary Drive (No Specific Event)
 
  Event Drive (includes an event with specific date & location)
 
Date, time, type, and location of Event:
(MM/DD/YYYY)Date/Time  
(e.g.:luncheon, dinner) Type:  
Location:  

Please list the preferred dates (month/day/year) for beginning and ending such solicitation(*):

Begin Date (MM/DD/YYYY):   End Date (MM/DD/YYYY) :  
(*)Per Article 8 CHARITABLE SOLICITATIONS of Chapter 3 of Title 4 of the Beverly Hills Municipal Code: 4-3-808: TERM OF PERMIT: A solicitation permit issued for an event pursuant to this article shall be valid for a period not to exceed one hundred and eighty (180) days from the date of issue, provided further, such permit may be extended for an additional period not exceeding an additional thirty (30) days upon filing a renewal application and demonstrating good cause for such extension. A solicitation permit issued for a monetary drive pursuant to this article shall be valid for a period not to exceed twelve (12) months from the date of issue.

N. Please give a full statement of the character and extent of the charitable or religious work being done by the applicant.


O. List other cities or counties where similar permits have been requested, and indicate if such permits were granted or denied.

If, while any application is pending, or during the term of any permit granted thereon, there is any change in fact, policy or method which would alter the information given in the applica-tion, the applicant shall notify the Director of Public Welfare in writing thereof within 24 hours after such change.

If a permit is granted, it will not be used or represented in any way as an endorsement by the City of Beverly Hills, or by any Department or Officer thereof. (Check this box if you agree :   If not, please explain below: ) 
 

Application must be signed by a corporate officer or by someone authorized to sign for the organization by a corporate resolution. A copy of the corporate resolution may be submitted with this application if it is not already on file with the commission.

 

I certify that the information provided in this Request for Permit to solicit is true and correct to the best of my knowledge.
 
   

Date (MM/DD/YYYY)

 Name and Title of Person Signing Application