Domestic Nonprofit Corporation Annual Report Form - Department Of Commerce And Consumer Affairs - 2010

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STATE OF HAWAII
DOMESTIC NONPROFIT CORPORATION
FILING FEE: $ 5.00
DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS
BUSINESS REGISTRATION DIVISION
H
Clear Form
335 Merchant Street
Mailing Address: Annual Filing, P.O. Box 40, Honolulu, HI. 96810
DOMESTIC NONPROFIT CORPORATION ANNUAL REPORT AS OF
CORPORATE NAME AND MAILING ADDRESS:
If the above mailing address has changed, line out and print change to the right.
If address of principal office differs from the above mailing address, state the address of principal office. Include City, State, and Zip
Code: _______________________________________________________________________________________________
1. The following is a brief description of the nature of activities which the corporation is actually conducting.
NATURE OF ACTIVITIES:
(To correct, line out and print corrections below. If inactive during the period, state INACTIVE.)
2. The name of the registered agent and the registered agent's street address of the place of business in Hawaii of the person to which
service of process and other notice and documents being served on or sent to the entity represented by it may be delivered to. (If any
change, line out and print change on the right. See reverse side for instructions.).
3
(List all officers and directors. Every corporation must have a minimum of three directors.)
. OFFICERS/DIRECTORS:
OFFICE HELD/
DIRECTOR CODE
ADDRESS (INCLUDE CITY, STATE & ZIP CODE)
NAME IN FULL
CERTIFICATION
I certify under the penalties of Section 414D-12, Hawaii Revised Statutes, that I have read the above, the information is true
and correct, and I am authorized to sign this report.
DATE:
Signature of authorized officer, attorney-in-fact
Print Name
for an officer, or receiver or trustee
(if the corporation is in the hands of a receiver or trustee)
FILE NO.
B18
Rev. 07/2010
B22
File this Original
(SEE REVERSE SIDE FOR INSTRUCTIONS)

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