C
K
OMMONWEALTH OF
ENTUCKY
A
L
G
, S
S
LISON
UNDERGAN
RIMES
ECRETARY OF
TATE
______________________________________________________________________________________________________
Division of Business Filings
Certificate of Authority
FBE
Business Filings
(Foreign Business Entity)
PO Box 718
Frankfort, KY 40602
(502) 564-3490
Pursuant to the provisions of KRS 14A and KRS 271B, 273, 274,275, 362 and 386 the undersigned hereby applies for authority to transact business in Kentucky
on behalf of the entity named below and, for that purpose, submits the following statements:
1. The entity is a :
profit corporation (KRS 271B).
nonprofit corporation (KRS 273).
professional service corporation (KRS 274).
business trust (KRS 386).
limited liability company (KRS 275).
professional limited liability company (KRS 275).
limited partnership (KRS 362).
2. The name of the entity is_________________________________________________________________________________________________________.
(The name must be identical to the name on record with the Secretary of State.)
3. The name of the entity to be used in Kentucky is (if applicable):__________________________________________________________________________.
(Only provide if "real name" is unavailable for use; otherwise, leave blank.)
4. The state or country under whose law the entity is organized is___________________________________________________________________________.
5. The date of organization is _______________________________________and the period of duration is _________________________________________.
(If left blank, the period of duration
is considered perpetual.)
6. The mailing address of the entity’s principal office is
_______________________________________________________________ _________________________ _______________ _____________________.
Street Address
City
State
Zip Code
7. The street address of the entity’s registered office in Kentucky is
_______________________________________________________________ _________________________ _______________ _____________________.
Street Address (No P.O. Box Numbers)
City
State
Zip Code
and the name of the registered agent at that office is _____________________________________________________________________________________.
8. The names and business addresses of the entity’s representatives (secretary, officers and directors, managers, trustees or general partners):
_______________________________ ________________________________ ________________________ _______________ ______________________
Name
Street or P.O. Box
City
State
Zip Code
________________________________ _______________________________ ________________________ ________________ ____________________
Name
Street or P.O. Box
City
State
Zip Code
________________________________ _______________________________ ________________________ ________________ ____________________
Name
Street or P.O. Box
City
State
Zip Code
9. If a professional service corporation, all the individual shareholders, not less than one half (1/2) of the directors, and all of the officers other than the secretary
and treasurer are licensed in one or more states or territories of the United States or District of Columbia to render a professional service described in the
statement of purposes of the corporation.
10. I certify that, as of the date of filing this application, the above-named entity validly exists under the laws of the jurisdiction of its formation.
11. If a limited partnership, it elects to be a limited liability limited partnership. Check the box if applicable:
12. This application will be effective upon filing, unless a delayed effective date and/or time is provided.
The effective date or the delayed effective date cannot be prior to the date the application is filed. The date and/or time is ______________________________.
(Delayed effective date and/or time)
_____________________________________________ _______________________________ _________________________
Signature of Authorized Representative
Printed Name & Title
Date
I, _________________________________________________________, consent to serve as the registered agent on behalf of the business entity.
Type/Print Name of Registered Agent
______________________________________ _________________________ _________________________ ____________
Signature of Registered Agent
Printed Name
Title
Date
(01/12)