Form Cra - Statement Of Consent Of Registered Agent (Domestic Or Foreign Business Entity) - 2012
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1
2C
K
OMMONWEALTH OF
ENTUCKY
A
L
G
, S
S
LISON
UNDERGAN
RIMES
ECRETARY OF
TATE
_________________________________________________________________________________________________________________________
Division of Business Filings
Business Filings
Statement of Consent of Registered Agent
CRA
PO Box 718
(Domestic or Foreign Business Entity)
Frankfort, KY 40602
(502) 564-3490
__________________________________________________________________________________________
Pursuant to the provisions of KRS 14A and KRS Chapter 271B, 273, 274, 275, 362 or 386, the undersigned applicant
consents to act as registered agent on behalf of the business entity named below and, for that purpose, submits the
following statements:
1. The business entity is
a corporation (KRS 271B, KRS 273 or KRS 274)
a limited liability company (KRS 275)
a limited partnership (KRS 362)
a limited liability partnership (KRS 362)
a business trust (KRS 386)
2. The name of the business entity is __________________________________________________________________.
3. The state or country of incorporation, organization or formation is __________________________________________.
4. The name of the initial registered agent is ____________________________________________________________.
5. The street address of the registered office address in Kentucky is:
_________________________________________________ ______________ _________________________ __________________
Street Address (No Post Office Box Numbers)
City
State
Zip Code
6. This application will be effective upon filing, unless a delayed effective date and/or time is provided. The effective date
or the delayed effective date cannot be prior to the date the application is filed. The date and/or time is ______________.
(Delayed effective
)
date and/or time
I declare under penalty of perjury under the laws of Kentucky that the forgoing is true and correct.
______________________________________ ________________________________ __________________________
Signature of Registered Agent
Printed Name
Title
(01/12)
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