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Form 401-A - Acceptance Of Appointment And Consent To Serve As Registered Agent - Texas Secretary Of State Page 3

401-A

Form

(Revised 12/09)

Acceptance of Appointment

and

Consent to Serve as Registered Agent

§5.201(b) Business Organizations Code

The following form may be used when the person designated as registered agent in a registered agent

filing is an individual.

Acceptance of Appointment and Consent to Serve as Registered Agent

I acknowledge, accept and consent to my designation or appointment as registered agent in Texas for

Name of represented entity

I am a resident of the state and understand that it will be my responsibility to receive any process,

notice, or demand that is served on me as the registered agent of the represented entity; to forward

such to the represented entity; and to immediately notify the represented entity and submit a statement

of resignation to the Secretary of State if I resign.

Signature of registered agent

Printed name of registered agent

Date (mm/dd/yyyy)

The following form may be used when the person designated as registered agent in a registered agent

filing is an organization.

Acceptance of Appointment and Consent to Serve as Registered Agent

I am authorized to act on behalf of

Name of organization designated as registered agent

The organization is registered or otherwise authorized to do business in Texas. The organization

acknowledges, accepts and consents to its appointment or designation as registered agent in Texas for:

Name of represented entity

The organization takes responsibility to receive any process, notice, or demand that is served on the

organization as the registered agent of the represented entity; to forward such to the represented entity;

and to immediately notify the represented entity and submit a statement of resignation to the Secretary

of State if the organization resigns.

Signature of person authorized to act on behalf of organization

Printed name of authorized person

Date (mm/dd/yyyy)

Reset

Form 401-A

Form 401-A - Acceptance Of Appointment And Consent To Serve As Registered Agent - Texas Secretary Of State Page 3