Secretary Of The State Of Connecticut Certificate Of Incorporation Stock Corporation Page 2
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44. APPOINTMENT OF REGISTERED AGENT:
(PLEASE SELECT ONLY ONE A. OR B AND PRINT OR TYPE NAME OF AGENT.)
A. INDIVIDUAL'S AGENT NAME:
BUSINESS ADDRESS:
RESIDENCE ADDRESS:
(P.O.BOX UNACCEPTABLE)
(P.O.BOX UNACCEPTABLE)
ADDRESS:
ADDRESS:
CITY:
CITY:
STATE:
ZIP:
STATE:
ZIP:
B. BUSINESS ENTITY:
ADDRESS:
(P.O.BOX UNACCEPTABLE)
ADDRESS:
CITY:
STATE:
ZIP:
ACCEPTANCE OF APPOINTMENT
SIGNATURE OF AGENT
5. OTHER PROVISIONS:
6. EXECUTION: CERTIFICATE MUST BE SIGNED BY EACH INCORPORATOR
DATED THIS
DAY OF
,20
NAME OF INCORPORATOR(S)
ADDRESS
SIGNATURE(S)
(print or type)
ADDRESS:
CITY:
STATE:
ZIP:
ADDRESS:
CITY:
STATE:
ZIP:
ADDRESS:
CITY:
STATE:
ZIP:
FORM CIS-1-1.0
PAGE 2 OF 2
Rev. 11/2012
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