Kentucky Secretary of State
T
G
REY
RAYSON
_________________________________________________________________________________________________
Division of Corporations
Statement of Consent of
CRA
B
F
USINESS
ILINGS
Registered Agent
P.O. Box 718
Frankfort, KY 40602
(502) 564-2848
________________________________________________________________________
Pursuant to the provisions of KRS Chapter 271B, 273, 275,362 or 386, the undersigned hereby
consents to act as registered agent on behalf of the business entity named below and for that
purpose submits the following statements:
The business entity is
a corporation (KRS 271B or KRS 273)
a limited liability company (KRS 275)
a limited partnership (KRS 362)
a limited liability partnership (KRS 362)
a business trust (KRS 386)
The name of the business entity is
_____________________________________________________________________________.
The state or country of incorporation, organization or formation is _________________________.
The name of the initial registered agent is
_____________________________________________________________________________.
The street address of the registered office address in Kentucky is
_____________________________________________________________________________.
Street
City
State
Zip Code
_____________________________________________
Signature of registered agent
_____________________________________________
Type or Print Name & Title, if applicable
Date: ______________________________, 20_______
CRA (06/07)
(See attached sheet for instructions)