Form Cr2e081 - Corporation Reinstatement - 2010 Page 2
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3PLEASE READ ALL INSTRUCTIONS BEFORE COMPLETING THIS FORM.
FLORIDA DEPARTMENT OF STATE
CORPORATION
Secretary of State
REINSTATEMENT
DIVISION OF CORPORATIONS
DOCUMENT #
1.
Corporation Name
2.
3.
Principal Office Address - No P.O. Box #
Mailing Office Address
CR2E081 (11/10)
Suite, Apt. #, etc.
Suite, Apt. #, etc.
4.
Date Incorporated or Qualified
To Do Business in Florida
City & State
City & State
5.
FEI Number
Applied For
Not Applicable
Zip
Country
Zip
Country
6.
$8.75
Additional Fee required
CERTIFICATE OF STATUS DESIRED
for a Certificate of Status
7.
Name and Address of Current Registered Agent
Name
Street Address (P.O. Box Number is Not Acceptable)
Suite, Apt. #, Etc.
City
State
Zip Code
FL
8.
I, being appointed the registered agent of the above named corporation, am familiar with and accept the obligations of section 607.0505 or 617.0503, F.S.
Signature of
Registered Agent
Date
REGISTERED AGENT MUST SIGN
9.
Names and Street Addresses of Each Officer and/or Director (Florida nonprofit corporations must list at least 3 directors)
Name of
Street Address of Each
Titles
City / State / Zip
Officers and /or Directors
Officer and /or Director
10.
E-mail Address:
(To be used for future annual report notification)
I certify that I am an officer or director or the receiver or trustee empowered to execute this application as provided for in chapter 607 or 617, F.S. I further certify that when filing this
11.
reinstatement application, the reason for dissolution has been eliminated, the corporate name satisfies the requirements of section 607.0401 or 617.0401, F.S., and that all fees
owed by the corporation have been paid. I further certify, the information indicated on this application is true and accurate, and my signature shall have the same legal effect as
if made under oath. I am aware that false information submitted in a document to the Department of State constitutes a third degree felony as provided for in s.817.155, F.S.
SIGNATURE:
SIGNATURE AND TYPED OR PRINTED NAME OF SIGNING OFFICER OR DIRECTOR
Date
Daytime Phone #
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