Forn Corp. 55a - Application For Certificate Of Authority Of A Foreign Nonprofit Corporation Page 2

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The effective date of this document is the date it is filed by the Secretary of State of Missouri, unless you indicate a future

date, as follows: _________________________________________________________________________________________

(Date may not be more than 90 days after the filing date in this Office)

In Affirmation thereof, the facts stated above are true and correct:

(The undersigned understands that false statements made in this filing are subject to the penalties provided under Section 575.040, RSMo)

________________________________________________________________________________________________________________

Authorized signature of officer of chairman of the board

Printed Name

Title

Date

Note: You must submit a current certificate of good standing or certificate of existence with this application. This may be obtained from the Secretary of State or other

authority that issues corporate charters.

Corp. 55A (01/05)