Form Mbca-12a - Amended Application For Authority To Do Business Page 2
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1
2DATED _________________________
*By ___________________________________________________
(signature of any duly authorized officer)
__________________________________________________
(type or print name and capacity)
*This document MUST be signed by any duly authorized officer.
(13-C MRSA
§121.5)
Please remit your payment made payable to the Maine Secretary of State.
SUBMIT COMPLETED FORMS TO: CORPORATE EXAMINING SECTION, SECRETARY OF STATE,
101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101
FORM NO. MBCA-12A (2 of 2) Rev. 7/1/2004
TEL. (207) 624-7752
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