Form Mllp-12d - Notification By Registered Agent Of Change In Name Or Registered Office Page 2
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1
2DATED
REGISTERED AGENT*
(signature)
(type or print name)
For Registered Agent which is a Corporation
Name of Corporation
By
(authorized signature)
(tyPe or print name aIxi capacity)
*Certificate ~
be signed by the re2istered 82ent (§854.3.B.).
The execution of this certificate constitutes an oath or affIrmation under the penalties of false swearing under Title 17-A, section 453.
SUBMIT COMPLETED FORMS TO: CORPORATE EXAMINING SECTION, SECRETARY OF STATE,
101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101
FORM NO. MLLP-12D Rev.7/2000
TEL. (207} 287-4195
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