Form 612 - Application For Transfer Of Authority - Rhode Island And Providence Plantations Secretary Of State Page 3

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SECTION II:
TO BE COMPLETED BY ENTITY TRANSFERRING AUTHORITY
Under penalty of perjury, I/we declare and affirm that I/we have examined this Application for Transfer of Authority,
including any accompanying attachments, and that all statements contained herein are true and correct and that the
undersigned is authorized to sign this certificate on behalf of the entity set forth in Section 1A.
Date:
Print Name of Other Entity
OR
Print Name of Partnership
By:
By:
Signature of Authorized Person
Signature of Partner
By:
By:
Signature of Authorized Person
Signature of Partner
By:
Signature of Partner
Print Name of Corporation
OR
Print Name of Limited Liability Company
By:
By:
Signature of Authorized Person
Signature of Authorized Person
By:
By:
Signature of Authorized Person
Signature of Authorized Person

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