Form 08-410 - Application For Certificate Of Authority (Page 2 of 2) in pdf

Form 08-410 - Application For Certificate Of Authority Page 2

10. The aggregate number of shares authorized to issue, itemized by classes, par value of shares, shares

without par value, and series, if any, within a class. (attach list if necessary)

Number of Shares

Class

Series

Par Value Per Share

11. The aggregate number of its issued shares, itemized by classes, par value of shares, shares without par

value, and series, if any, within a class. (attach list if necessary)

Number of Shares

Class

Series

Par Value Per Share

12. The name and address of each person owning at least 5% of the shares, or 5% of any class of shares, and

the percentage of the shares or class of shares owned by that person (attach list if necessary):

Dated

, 19

Exact Corporate Name

By:

Its President or Vice President

and By:

Its Secretary or Assistant Secretary

Subscribed and sworn to be me this ______ day of _____________________________________, ______.

_____________________________________________________

Notary Public in and for __________________________________

My Commission Expires: ________________________________

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08-410 (5/99)

Form 08-410 - Application For Certificate Of Authority Page 2