Form Cxm-1-1.0 - Appointment Of Attorney For Service Of Process Amusements/circuses, Fireworks And Vendors (Cigarettes) Page 2

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THE ABOVE NAMED INDIVIDUAL APPOINTS THE SECRETARY OF THE STATE OF CONNECTICUT AND HIS SUCCESSORS IN OFFICE, TO BE
HIS (HER) AGENT FOR SERVICE OF PROCESS UPON WHOM ALL PROCESS, IN ANY ACTION OR PROCEEDING AGAINST HIM (HER) WHICH
IS SERVED ON THE SECRETARY OF THE STATE SHALL BE OF THE SAME LEGAL FORCE AND VALIDITY AS IF SERVED ON HIM (HER), AND
THAT THIS APPOINTMENT SHALL CONTINUE IN FORCE AS LONG AS ANY LIABILITY REMAINS OUTSTANDING AGAINST HIM (HER) IN
CONNECTICUT.
3. AUTHORIZATION:
DATED THIS
DAY OF
, 20
NAME OF SIGNATORY
CAPACITY/TITLE OF SIGNATORY
SIGNATURE
PERSONALLY APPEARED THE ABOVE NAMED PERSON AND ACKNOWLEDGED THE SAME TO BE HIS FREE ACT AND DEED, BEFORE ME.
DATE
SIGNATURE (NOTARY PUBLIC)
FORM CXM-1-1.0
PAGE 2 OF 2
Rev. 7/2010

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