Jurisdiction under which the
entity was formed
______________________________________________________
ID number
_____________________
(if applicable)
Principal office street address
______________________________________________________
(Street name and number)
______________________________________________________
__________________________ _____ ____________________
(City)
(State)
(Postal/Zip Code)
_______________________ ______________
(Province – if applicable)
(Country – if not US)
Principal office mailing address ______________________________________________________
(if different from above)
(Street name and number or Post Office Box information)
______________________________________________________
__________________________ _____ ____________________
(City)
(State)
(Postal/Zip Code)
_______________________ ______________
(Province – if applicable)
(Country – if not US)
Entity name or true name
(other than the surviving entity)
____________________________________________________
(Enter name exactly as it appears in the records of the secretary of state if applicable)
Form of entity
______________________________________________________
Jurisdiction under which the
entity was formed
______________________________________________________
ID number
_____________________
(if applicable)
Principal office street address
______________________________________________________
(Street name and number)
______________________________________________________
__________________________ _____ ____________________
(City)
(State)
(Postal/Zip Code)
_______________________ ______________
(Province – if applicable)
(Country – if not US)
Principal office mailing address ______________________________________________________
(if different from above)
(Street name and number or Post Office Box information)
______________________________________________________
__________________________ _____ ____________________
(City)
(State)
(Postal/Zip Code)
_______________________ ______________
(Province – if applicable)
(Country – if not US)
(If there are more than three merging entities, mark this box
and include an attachment stating the entity name, ID
number, and the principal office address of each additional merging entity.)
2. Entity name of the surviving entity
______________________________________________________
(Enter name exactly as it appears in the records of the secretary of state if applicable)
MERGE
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Rev. 5/22/2007