Facsimile Signature Filing Form - State Of Missouri
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1State of Missouri
COMMISSIONS DIVISION
PO BOX 784
Secretary of State
JEFFERSON CITY, MISSOURI 65102
(573) 751-4756
Facsimile Signature Filing Form
STATE OF MISSOURI
COUNTY OF
I, the undersigned,
, being duly sworn, do hereby state
upon my oath that I am the duly qualified and acting
of the
in the City of
,
County, Missouri,
and that the signature appearing below is my signature and I file this certificate pursuant to Section
105.274, RSMo 1994.
(Please sign manually)
Subscribed and sworn to before me,
, Notary Public for
County, Missouri, this
day of
.
(Notary Public)
Typed or printed name
(SEAL)
State of
Commissioned for
County
My commission expires
NOTE: Notaries must affix the required typed, printed or rubber stamped information required by
law as well as an embosser seal or a black ink notary seal.
Comm. 49 (10-00)
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