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State of North Carolina

Department of the Secretary of State

APPLICATION BY FOREIGN PROFESSIONAL CORPORATION

FOR AMENDED CERTIFICATE OF AUTHORITY

Pursuant to Section

55B-16 of the General Statutes of North Carolina, the undersigned foreign professional corporation (defined in

N.C.G.S. §55B-16) hereby applies for an Amended Certificate of Authority to transact business in the State of North Carolina, and

for that purpose submits the following representations:

1. The name of the corporation is: _____________________________________________________________________________

2. The name the corporation is currently using in the State of North Carolina is:_________________________________________

_______________________________________________________________________________________________________

3. The state or country of incorporation is:_______________________________________________________________________

4. The date the corporation was authorized to transact business in the State of North Carolina is:____________________________

_______________________________________________________________________________________________________

5. The personal services to be rendered by the corporation are:_______________________________________________________

_______________________________________________________________________________________________________

6. With respect to each professional service to be practiced through the corporation in this State, the names and titles of at least one

of the corporation’s directors and at least one of its officers who are licensees of the licensing board which regulates such

profession in this State are: (use attachment if necessary)

Name

Title

7. Attached are certifications by the appropriate licensing boards that each person set forth in Item 6 above is a “licensee” as

defined in N.C.G.S. §55B-2(2).

8. This application is filed for the following reason (complete all applicable items):

a. The corporation has changed its corporate name to:___________________________________________________________

b. The name the corporation will hereafter use in the State of North Carolina is changed to:_____________________________

____________________________________________________________________________________________________

c. The corporation has changed its period of duration to:_________________________________________________________

d. The corporation has changed its state or country of its incorporation to:___________________________________________

e. (Other)______________________________________________________________________________________________

____________________________________________________________________________________________________

9. Attached is a certificate setting forth and attesting to the change, duly authenticated by the secretary of

state or other

official having custody of corporate records in the state or country of incorporation.

10. If the corporation is required to use a fictitious name in order to transact business in this State, a copy of the resolution of its

board of directors, certified by its secretary, adopting the fictitious name is attached.

PC-03

Form Pc-03 - Application By Foreign Professional Corporation For Amended Certificate Of Authority - 2000