Interim Notice Of Change Of Officer/director
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1INTERIM NOTICE OF CHANGE OF OFFICER/DIRECTOR
Domestic and Foreign Corporations
Office of the Secretary of the State
30 Trinity Street / P.O. Box 150470 / Hartford, CT 06115-0470 / Rev. 12/1999
Please see reverse for instruction.
Space For Offke Use Only
1. Name of Corporation:
2. New offker/director
information:
Name
(street address required
-
P.O. Box not
acceptable)
Title
Residence Address
Business Address
I
Check if
director
I
Check if
director
I
Check if
director
I
Check if
director
I
Checkif
director
I
Check if
director
3. Directors/offkers
who have ceased to hold office:
Name
Title
Name
Title
q
Check if director
D Check if director
q
Check if director
q
Check if director
Note: If additional space is needed, please reference an 8 112 X 11 attachment
4. EXECUTION:
Dated this
day of
,20
.
Print or type name of signatory
Capacity of signatory
Signature
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