Non-Stock Application For Certificate Of Authority Form Page 2
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2The application must be signed, in the presence of a notary public, by the chairman of the board of directors, or by the president or by
another officer.
I DECLARE AND AFFIRM UNDER THE PENALTY OF PERJURY THAT THIS APPLICATION IS IN ALL THINGS, TRUE
AND CORRECT.
Dated _________________
__________________________________________________
(Signature)
__________________________________________________
STATE OF ___________________________
(Title)
__________________________
COUNTY OF
I, _______________________________________, a notary public, do hereby certify that on this _______ day of ___________________, 20____,
personally appeared before me ________________________________________________ who, being by me first duly sworn, declared that he/she
is the ____________________________ of _____________________________________________, that he/she signed the foregoing document as
officer of the corporation, and the statements therein contained are true.
_______________________________
__________________________________________________
My Commission Expires
(Notary Public)
Notarial Seal
***********************************************************************************************************
The Consent of Appointment below must be signed by the registered agent.
Consent of Appointment by the Registered Agent
I, ______________________________________________, hereby give my consent to serve as the registered
(name of registered agent)
agent for ________________________________________________________________________________.
(corporate name)
Dated ____________________
________________________________
(signature of registered agent)
FILING FEE: $100 Make checks payable to the Secretary of State
An ORIGINAL and ONE EXACT OR CONFORMED COPY of the application must be submitted together with a currently dated
CERTIFICATE OF EXISTENCE duly acknowledged by the Secretary of State or other official having custody of corporate records
in the state or country under whose laws it is incorporated.
nonprofitnonstockcertificateofauthority Jan 2006
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