Form Pllc-01 , Application For Certificate Of Authority Page 4
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4APPLICATION FOR CERTIFICATE OF AUTHORITY
Page 3
By executing this application on behalf of the applicant limited liability company, I certify under oath that the
undersigned limited liability company is a “foreign professional limited liability company” within the scope of
N.C.G.S. Sections 57D-2-02 and 55B-16(b).
____________________________________________________
Name of Limited Liability Company
____________________________________________________
Signature of Company Official
____________________________________________________
Type or Print Name & Title
__________________________
(Site of acknowledgment)
__________________________
This ____ day of ______________, 20____, personally came before me, ______________________________________,
Notary Public, __________________________________, who, being by me duly sworn, says that he/she is
____________________________ of __________________________________________________, a professional
limited liability company, and that this application for certificate of authority was signed by him/her on behalf of the
professional limited liability company by its authority duly given. And the said _________________________________
acknowledged the said writing to be the act and deed of said professional limited liability company.
Witness my hand and official seal, this the ____ day of ________________, 20____.
(Official Seal)
____________________________________________________
Notary Public
My commission expires _______________, 20____.
Notes:
1. Filing fee is $250. This document must be filed with the Secretary of State.
2. Only a “foreign professional limited liability company” may use this application. To determine whether a particular limited
liability company is such a “foreign professional limited liability company”, it is necessary to examine the requirements of
N.C.G.S. Sections 57D-2-02 and 55B-16(b), copies of which are attached. If the company does not meet the requirements
of a “foreign professional limited liability company” as set forth in those statutes, it must use the standard application for
certificate of authority for a limited liability company, available from this office.
CORPORATIONS DIVISION
PO BOX 29622
RALEIGH, NC 27626-0622
Revised January, 2014
Form PLLC-01
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