Form Pllc-01 , Application For Certificate Of Authority Page 3
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4APPLICATION FOR CERTIFICATE OF AUTHORITY
Page 2
8. The names, titles, and usual business addresses of the current company officials of the limited liability company are:
(use attachment if necessary)
Name and Title
Business Address
___________________________________________
___________________________________________________
___________________________________________
___________________________________________________
___________________________________________
___________________________________________________
___________________________________________
___________________________________________________
___________________________________________
___________________________________________________
___________________________________________
___________________________________________________
9. Attached is a certificate of existence (or document of similar import), duly authenticated by the secretary of state or
other official having custody of limited liability company records in the state or country of organization.
10. If the limited liability company is required to use a fictitious name in order to transact business in this State, a copy
of the resolution of its managers adopting the fictitious name is attached.
11. The personal services to be rendered by the limited liability company are ___________________________________
______________________________________________________________________________________________
12. With respect to each professional service to be practiced through the limited liability company in this State, the name
of at least one of the limited liability company’s company officials who is a licensee of the licensing board which
regulates such profession in this State is: (insert name here)
13. Attached are certifications by the appropriate licensing boards that each individual set forth in Item 13 above is a
“licensee” as defined in N.C.G.S. Section 55B-2(2).
14. This application will be effective upon filing, unless a delayed date and/or time is specified: ____________________
This the ____day of ________________, 20___.
CORPORATIONS DIVISION
PO BOX 29622
RALEIGH, NC 27626-0622
Revised January, 2014
Form PLLC-01
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