STATE OF NORTH CAROLINA
DEPARTMENT OF THE SECRETARY OF STATE
AMENDMENT OF STATEMENT OF APPOINTMENT OF AGENT
Pursuant to §59B-11 of the General Statutes of North Carolina, the undersigned entity submits the following for the purpose of
amending its statement of appointment of agent.
INFORMATION CURRENTLY ON FILE
The name of the entity is: _________________________________________________________________________________
The street address and county of the entity’s office currently on file is:
Number and Street: __________________________________________________________________________________________
City, State, Zip Code: ________________________________________
County: ___________________________________
The mailing address if different from the street address of the office currently on file is:
__________________________________________________________________________________________________________
The name of the current agent is: ______________________________________________________________________
NEW INFORMATION
1. The street address and county of the new office of the entity is:
(Complete this item only if the address of the registered office is being changed)
Number and Street: _______________________________________________________________________________________
City, State, Zip Code: _______________________________________ County: ______________________________________
2. The mailing address if different from the street address of the new office is:
(Complete this item only if the address of the office is being changed)
______________________________________________________________________________________________________
3. The name of the new agent and the new agent’s consent to appointment appears below:
(complete this item only if the name of the agent is being changed)
______________________________________________
__________________________________________________
Type or Print Name of New Agent
* Signature & Title
4. This statement will be effective upon filing, unless a date and/or time is specified: _____________________________________
_________________________________________
This is the _____day of _______________, 20____.
Entity Name
__________________________________________
Signature
__________________________________________
Type or Print Name and Title
Notes:
Filing fee is $5.00. This document must be filed with the Secretary of State.
.
* Instead of signing here, the new agent may sign a separate written consent to the appointment, which must be attached to this statement
CORPORATIONS DIVISION
P. O. BOX 29622
RALEIGH, NC 27626-0622
January 2007
Form NA-02