Form Nfp-104.25 - Application For Registration, Renewal Or Cancellation Of Foreign Corporation Name - Illinois Secretary Of State

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Application for Registration,
Form NFP-104.25
Renewal or Cancellation of Foreign
File #:
(Rev. Jan. 2003)
Corporation Name Under the General
DO NOT SEND CASH
Secretary of State
Not For Profit Corporation Act
This space for use by
Department of Business Services
Secretary of State.
Springfield, IL 62756
217-782-6961
Date:
Filing Fee:
$
Remit payment in the form of a
check or money order, payable to
Approved:
Secretary of State.
Pursuant to the provisions of The General Not For Profit Corporation Act of 1986, the undersigned corporation hereby sub-
mits the following application.
1. Corporate Name: ________________________________________________________________________________
2. State or Country of Incorporation: ___________________________________________________________________
3. Date of Incorporation: ____________________________________________________________________________
4. Affairs the corporation is conducting:_________________________________________________________________
5. Post office address of the corporation to which the Secretary of State may mail notices:
______________________________________________________________________________________________
______________________________________________________________________________________________
6. The corporation desires to register its corporate name pursuant to Section 104.25 and it is not conducting affairs in the
State of Illinois at this time.
7. Attached to this application is a certificate setting forth that the corporation is in good standing under the laws of the
State or Country wherein it is organized, executed by the proper officer of the State or Country wherein it is organized,
which certificate shall not be more than ninety (90) days old.
8. Check appropriate box:
❏ Registration fee — $50
❏ Renewal fee — $50
❏ Cancellation fee — $5
9. Such registration shall be effective from the date of filing by the Secretary of State until the first day of the 12th month
following such date. A renewal shall extend the registration 12 months.
10. A cancellation shall be effective upon filing with the Secretary of State.
11. The undersigned corporation has caused this statement to be signed by a duly authorized officer who affirms, under
penalties of perjury, that the facts stated herein are true and correct.
Dated _______________________________ , _____
________________________________________________
Month & Day
Year
Exact Name of Corporation
______________________________________
Any Authorized Officer’s Signature
______________________________________
Name and Title (type or print)
Printed by authority of the State of Illinois. June 2006 — 1M — C 223.6

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