________________________________________________________________________
Address
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Vice President Name
________________________________________________________________________
Address
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Secretary Name
________________________________________________________________________
Address
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Treasurer Name
________________________________________________________________________
Address
________________________________________________________________________
Director Name
________________________________________________________________________
Address
________________________________________________________________________
Corporate Name
________________________________________________________________________
Signature of President or Vice President
_________________________________________________________
Signature of Secretary or Assistant Secretary
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(Corporate Seal)
File in duplicate originals - Filing Fee .........$200.00
Attach written consent of registered agent
Attach an original certificate of good standing not over 30 days old