(Seal of Corporation)
For Corporation, etc. ___________________________
_____________________________________________
(Name of Corporation)
BY ____________________________________
(Name)
ITS: ___________________________________
For Limited Liability Corporation, Limited Liability
Partnership ___________________________________
BY ___________________________________
(its Managing Member/Shareholder)
This application must be executed by a principal officer, partner or principal on behalf of the Applicant.
STATE OF ______________________________
SS.
COUNTY OF ____________________________
The undersigned being duly sworn deposes and says that he has executed the foregoing applications
for and on behalf of the applicant named therein; that he is
of such applicant and is fully authorized to execute and file such application; that he is familiar with such
application; and that to the best of his knowledge, information and belief, the statements made in such
application and the statements made in the exhibits submitted therewith, are true.
Subscribed and sworn to before me this
______ day of _____________ , 20
(Notary Public)
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