DATED __________________________
REGISTERED AGENT*
___________________________________________________
____________________________________________________
)
(signature)
(type or print name
For Registered Agent which is a Corporation
Name of Corporation ______________________________________________________________________________________________
By ________________________________________________
____________________________________________________
(authorized signature)
(type or print name and capacity)
*Certificate MUST be signed by the registered agent.
The execution of this certificate constitutes an oath or affirmation under the penalties of false swearing under Title 17-A, section 453.
SUBMIT COMPLETED FORMS TO: CORPORATE EXAMINING SECTION, SECRETARY OF STATE,
101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101
FORM NO. MLPA-12D
Rev. 4/16/2001
TEL. (207) 624-7740