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2. This application is for use by charitable, non-profit organizations applying to Roanoke County for a permit to solicit or cause a solicitation to be made within Roanoke County. Please answer all questions. All fields are required.
   
   If you need more information, please call the Clerk's Office at 540-772-2005 or email us.
4. Applicant Information
6. Applicant Name:(Person submitting request, not organization)
   *
8. Applicant Street Address:*
10. City:*
11. State:*
12. ZIP:*
14. Phone:*
15. Email:*
17. Event Information
19. Dates on which solicitation will begin and end
    (NOT TO EXCEED 90 DAYS AND TO BE CONDUCTED ONLY BETWEEN 9:00 A.M. AND 9:00 P.M.):*
21. Organization Information (organization receiving proceeds from solicitation)
23. Name of organization receiving proceeds from solicitation:
    *
25. Address:*
27. City:*
28. State:*
29. ZIP:*
31. Purpose for which any receipts derived from the solicitation are to be used: *
33. Principal Officer or Manager of the applicant, if applicant is other than an individual:*
35. Address:*
37. City:*
38. State:*
39. ZIP:*
41. Name of the person by whom the receipts of the solicitation will be received and dispersed:*
43. Person who will be in direct charge of conducting the solicitation:
    
45. Name:*
47. Address:*
49. City:*
50. State:*
51. ZIP:*
53. Outline the method to be used in conducting the solicitation:*
55. Provide a full statement of the character and extend of the charitable, education or philanthropic work being done in Roanoke County by the organization receiving proceeds from the solicitation:*
57. Federal tax employer identification number:*
59. State tax-exempt identification numbers:*
61. Federal tax-exempt identification numbers:*
63. Effective July 1, 2002, HB731 of the 2002 Virginia General Assembly updated the Virginia Freedom of Information Act. Email subscribers receiving information from a public body may, at their request, be exempt from having their email address given out should the email list be requested under the Freedom of Information Act (FOIA). If you would like to be exempted, please call (540) 772-2003.
Leave This Blank:


65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit Submit and Print

* indicates a required field