Form Mllc-12a - Amended Application For Authority To Do Business Page 2
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1
2DATED __________________________
Manager(s)/Member(s)*
___________________________________________________
__________________________________________________
(signature)
(type or print name and capacity)
For Manager(s)/Member(s) which are Entities
Name of Entity _______________________________________________________________________________________________
By ________________________________________________
__________________________________________________
(authorized signature)
(type or print name and capacity)
The limited liability company name as used in the State of Maine must contain one of the following: "Limited Liability Company",
"L.L.C." or "LLC"
(31 MRSA
§603-A). If the addition of these words is the only difference from the limited liability company's real
name in its jurisdiction of organization, no further action is required.
*Certificate MUST be signed by:
(1) at least one manager OR
(2) at least one member if the limited liability company is managed by the members OR
(3) any duly authorized person.
The execution of this certificate constitutes an oath or affirmation under the penalties of false swearing under
17-A MRSA
§453.
Please remit your payment made payable to the Maine Secretary of State.
SUBMIT COMPLETED FORMS TO: CORPORATE EXAMINING SECTION, SECRETARY OF STATE,
101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101
FORM NO. MLLC-12A (2 of 2) Rev. 8/1/2004
TEL. (207) 624-7752
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