Form Cf-1 - Certificate Of Authority - 2013 (Page 3 of 3) in pdf

Form Cf-1 - Certificate Of Authority - 2013 Page 3

APPLICATION FOR CERTIFICATE OF AUTHORITY

Page 3

10. The number of acres of land it holds or expects to hold in West Virginia is: __________________

11. Contact and Signature Information* (See below Important Legal Notice Regarding Signature):

a. ____________________________________________ ___________________________________

Contact Name

Phone Number

b. ____________________________________________ ___________________________________

Print or type name of signer

Title / Capacity of Signer

c. _____________________________________________ __________________________________

Signature

Date

* Important Legal Notice Regarding Signature: Per West Virginia Code §31D-1-129. Penalty for

signing false document. Any person who signs a document he or she knows is false in any material respect

and knows that the document is to be delivered to the secretary of state for filing is guilty of a misdemeanor

and, upon conviction thereof, shall be fined not more than one thousand dollars or confined in the county or

regional jail not more than one year, or both.

Form CF-1

Issued by the Office of the Secretary of State

Revised 8/13

Form Cf-1 - Certificate Of Authority - 2013 Page 3