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Form Pc-03 - Application By Foreign Professional Corporation For Amended Certificate Of Authority - 2000 Page 2

11.

This application will be effective upon filing, unless a date and/or time not later than 90 days after the

date of filing is

specified:______________

This the ____________day of _____________________________, 20______.

By executing this application on behalf of the applicant corporation, I certify under oath that the undersigned corporation is a

“foreign professional corporation” as that term is defined in N.C.G.S. §55B-16(b).

________________________________________________

Name of Corporation

________________________________________________

Signature of Officer or Chairman of Board of Directors

________________________________________________

Type or Print Name and Title

__________________________

(site of acknowledgment)

__________________________

This ____ day of ______________, 20____, personally came before me, ______________________________________,

Notary Public, __________________________________, who, being by me duly sworn, says that he/she is

____________________________ of __________________________________________________, a corporation, and

that this application for certificate of authority was signed by him/her on behalf of the corporation by its authority duly

given. And the said _________________________ acknowledged the said writing to be the act and deed of said

corporation.

Witness my hand and official seal, this the ____ day of ________________, 20____.

(Official Seal)

____________________________________________________

Notary Public

My commission expires _______________, 20____.

Notes:

1. Filing fee is $50. One executed original and one exact or conformed copy of this application must be filed with the Secretary of State.

(Revised January 2000)

(Form PC-03)

CORPORATIONS DIVISION

P.O. BOX 29622

RALEIGH, NC 27626-0622

PC-03

Form Pc-03 - Application By Foreign Professional Corporation For Amended Certificate Of Authority - 2000 Page 2