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Form Pc-01 - Application For Certificate Of Authority Foreign Professional Corporation - 2000

State of North Carolina

Department of the Secretary of State

APPLICATION FOR CERTIFICATE OF AUTHORITY

FOREIGN PROFESSIONAL CORPORATION

Pursuant to Section 55B-16 of the General Statutes of North Carolina, the undersigned corporation hereby applies for a Certificate of

Authority to transact business in the State of North Carolina as a “foreign professional corporation” (as defined in N.C.G.S. Section

55B-16(b)), and for that purpose submits the following:

1. The name of the corporation is _______________________________________________________________________________;

and if the corporate name is unavailable for use in the State of North Carolina, the name the corporation wishes to use is:

_______________________________________________________________________________________________________

2. The state or country under whose laws the corporation was incorporated is: ___________________________________________

3. The date of incorporation was ____________________________; its period of duration is: _______________________________

4. The street address of the principal office of the corporation is:

Number and Street ________________________________________________________________________________________

City, State, Zip Code ______________________________________________________________________________________

5. The mailing address if different from the street address of the principal office of the corporation is:

_______________________________________________________________________________________________________

6. The street address and county of the registered office in the State of North Carolina is:

Number and Street _______________________________________________________________________________________

City, State, Zip Code __________________________________________________ County _____________________________

7. The mailing address if different from the street address of the registered office in the State of North Carolina is:

_______________________________________________________________________________________________________

8. The name of the registered agent in the State of North Carolina is: ___________________________________________________

9. The names, titles, and usual business addresses of the current officers of the corporation are:

(use attachment if necessary)

Name

Title

Business Address

PC-01

Form Pc-01 - Application For Certificate Of Authority Foreign Professional Corporation - 2000