APPLICANT�S NAME:

CONTROL PERSONS

The applicant must provide the following information on each person who directly or indirectly,

has the power to direct or cause the direction of the management and policies of the applicant.

The term control person includes, but is not limited to,

each executive officer or person holding similar position.

Make additional copies of this form as needed.

(Please type or print)

Name:

Title:

Address:

City:

State:

Zip Code:

Date of Birth:

Social Security Number:

The person named above MUST provide a ten year employment history

beginning with the most recent employment.�

Attach separate sheets if needed.

All persons who have custody of charitable donations must submit to a criminal background check.

The person named above authorizes the Secretary of State to

conduct a criminal history check pursuant to a

registration as a charitable organization in the State of Georgia.

Signature of Control Person

This

Day of

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