Form Consent To Service Of Process - Vt Securities Division
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1VERMONT SECURITIES DIVISION
CONSENT TO SERVICE OF PROCESS
KNOW ALL MEN BY THESE PRESENTSthat the undersigned _________________________________
___________________________(a corporation) (a partnership), (a______________) organized under the laws of
__________________, or (an individual)[strike out inapplicable nomenclature] for purposes of complying with the
laws of the State of Vermont, hereby irrevocably appoints the Commissioner of Banking, Insurance, Securities and
Health Care Administration (“Commissioner”) for the State of Vermont and his/her successors in office, its attorney
in Vermont upon whom may be served any notice, process or pleading in any action or proceeding against it arising
out of, or in connection with, the sale of securities or out of violation of the aforesaid laws of the State of Vermont;
and the undersigned does hereby consent that any such action or proceeding against it may be commenced in an
administrative forum or in any court of competent jurisdiction, and proper venue within the State of Vermont by
service of process upon the Commissioner with the same effect as if the undersigned was organized or created under
the laws of the State of Vermont and have` been served lawfully with the process in the State of Vermont.
It is requested that a copy of any notice, process or pleading served hereunder be mailed
to:_______________________________________________________________________ .
Dated this_____ day of _____________________, _____ .
_________________________________________________
By:
_________________________________________________
_________________________________________________
Title
CORPORATE/LLC ACKNOWLEDGMENT
State or Province of __________________}
County of _______________________________} ss.
On this ___________ day of ____________________, _____, before me personally appeared
_____________________________________known personally to me to be the ______________________
(title) of the above-named (corporation) (LLC) and acknowledged the s/he, as an (officer) (LLC) being authorized so
to do, executed the foregoing instrument for the purposes therein contained, by signing the name of the (corporation)
(LLC) by him/herself as an (officer) (member).
IN WITNESS WHEREOF, I have hereunto set my hand and official seal.
__________________________________________________
Notary Public/Commissioner of Oaths
(SEAL)
My Commission Expires: _____________________________
INDIVIDUAL, PARTNERSHIP, OR LLP ACKNOWLEDGMENT
State or Province of _____________________}
County of _____________________________} ss.
On this ________ day of _________________________, _______, before me personally appeared
_______________________________ known personally to me to be the same person(s) whose name(s) is (are)
signed to the foregoing instrument, and acknowledged the execution thereof for the uses and purposes therein set
forth.
IN WITNESS WHEREOF, I have hereunto set my hand and official seal.
__________________________________________________
(SEAL)
Notary Public/Commissioner of Oaths
My Commission Expires:_____________________________
Revised 7/17/00
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