11. Name and address of each person/entity owning 5% or more of the issued shares or 5% of any class of
issued shares and the percentage of the issued shares owned by that person. If there are no person/entity
owning 5% or more please indicate with “NONE”. Attach an additional page if necessary.
If you have shareholders
please complete #9
Name
Mailing Address
City
State
ZIP Code
%
Issued
Shares Held
12. If entity is a Cooperative Corporation, list the name and mailing address of at least one member residing in
Alaska:
Name:
Mailing Address:
City:
AK
ZIP Code:
13. The PRINTED name and SIGNATURE of the President or Vice President of the corporation, and its
Secretary or an Assistant Secretary, is required. If the same person holds two of these positions, two different
people must sign the application unless one person holds all positions.
By signing this application for Certificate of Authority, I attest that the information set forth above is true
and correct.
Signature of President or Vice President
Printed Name
Date
__ / __ / __
Signature of Secretary or Assistant Secretary
Printed Name
Date
__ / __ / __
To resolve questions with this filing: Please be aware, this form will become public information.
Contact Name
Contact Phone Number
If you have specific legal questions or concerns about this filing, you are strongly advised to consult an
attorney or other professional to assist you.
Mail pages 1-- 4 and the appropriate filing fee (in U.S. dollars).
$350.00 Foreign Business Corporation
$350.00 Foreign Cooperative Corporation
$50.00 Non-Profit Corporation
Mail to: State of Alaska
Corporations Section
PO Box 110806
Juneau, AK 99811-0806
For additional information or forms please visit our web site at:
08-410 (Rev. 02/24/10)
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