Form No. 23-34.1-14 Designation Of Agent For Nonresident Owners Of Amusements
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1STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
Office of the Secretary of State
Corporations Division
148 W. River Street
Providence, Rhode Island 02904-2615
DESIGNATION OF AGENT FOR NONRESIDENT OWNERS OF AMUSEMENTS
________
Pursuant to the provisions of Section 23-34.1-14 of the General Laws, 1956, as amended, the undersigned owner of
amusements, who is not a resident of the State of Rhode Island, submits the following statement for the purpose of
appointing the Secretary of State of the State of Rhode Island and his or her successors in office to be his or her attorney,
upon whom all process in any action or proceeding against him or her may be served.
1. The name of the nonresident owner is
2. The address of the nonresident owner to which the secretary of state shall mail a copy of any process against the
owner that may be served on him or her is
3. The owner named in item 1 above agrees that any process against him or her which is served on the secretary of state
shall be of the same legal force and validity as if served on him or her as such owner, and that such appointment shall
continue in force as long as any liability remains outstanding against the owner in this state.
Date:
Signature of Owner
STATE OF
COUNTY OF
In ____________________________, on this ________ day of _________________________, _______,
personally appeared before me ______________________________________________________________, an owner
of amusements, who, under oath, verified that the information contained in this document is true and accurate.
Notary Public
My Commission Expires:
Form No. 23-34.1-14
Revised: 12/05
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