Resident Agent Appointment Form - Department Of Consumer & Regulatory Affairs

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Resident Agent
Appointment Form
A non-resident of the District of Columbia who wishes to transact business in the District shall appoint a Resident Agent or an
Attorney-in-Fact who resides or maintains an office in the District of Columbia upon whom all fiduciary and other process or
legal notice directed to the Applicant may be served upon the appointed Resident Agent. Applicant and named Resident
Agent must complete and sign this Resident Agent Form.
I, _____________________________________________________, hereby appoint _________________________________________
of _____________________________________________________________________________________________ at (address)
______________________________________________________________________________________________________________
Telephone _______________________________________ as my resident agent for all fiduciary and other process or legal
notice directed to the Applicant shall be served.
Signed by:
Agreed to by:
Owner/Proprietor _________________________________
Resident Agent _______________________________________
Print Name ______________________________________
Print Name __________________________________________
Date ____________________________________________
Date ________________________________________________
Department of Consumer & Regulatory Affairs  1100 4th Street, SW  Washington, DC 20024
(202) 442-4311  (202) 442-4523 (fax)  For Relay Service Call 711
____________________________________________________________________________________________
INSTRUCTIONS FOR COMPLETING THE RESIDENT AGENT APPOINTMENT FORM
Non-residents of the District of Columbia that want to conduct business in the District must appoint a Resident Agent.
Please complete the form, sign and date and attach your application for a Basic Business License. Applicant must indicate
the following:
I,
(insert name of applicant/business
owners), hereby appoint
(indicate contact/individual’s
name) of
(print company
name)
at
(print full street address in the
District), Telephone
(print contact’s telephone
number) as my resident agent for all
fiduciary and other process or legal notice directed to the Applicant shall be served.
Signatures: both the Applicant (Owner/Proprietor) and Resident Agent must sign, print their names and date the Resident
Agent Appointment Form prior to attaching to application.
CRIMINAL PENALTIES FOR MAKING FALSE STATEMENTS
Any person convicted of making false statements shall be fined not more than $1,000 or imprisoned for not more than 180 days, or both. A person commits
the offense of making false statements if that person willfully makes a false statement that is in fact material, in writing, directly or indirectly to any
instrumentality of the District of Columbia government, under circumstance in which the statement could reasonably be expected to be relied upon as true.
(DC Code 22-2405)
DC INSPECTOR GENERAL HOTLINE
If you are aware of corruption, fraud, waste abuse or mismanagement involving any DC government agency, official or program, contact the Office of the
Inspector General (OIG) at the OIG Hotline, (202) 727-0267 or (800) 521-1639 (toll free). All reports are confidential and you may remain anonymous. By
law, government employees are protected from reprisals or retaliation by their employers for reporting to the OIG. The information you provide may result in
an investigation leading to administrative action, civil penalties or criminal prosecution in appropriate cases.
NOTICE OF NON-DISCRIMINATION
In accordance with the DC Human Rights Act of 1977, as amended, DC Code section 2.1401.01 et seq., (“the Act”) the District of Columbia does not
discriminate on the basis of race, color, religion, national origin, sex, age, marital status, personal appearance, sexual orientation, familial status, family
responsibilities, matriculation, political affiliation, disabilities, source of income, or place of residents or business. Discrimination in violation of the act will not
be tolerated. Violators will be subject to disciplinary action.
12-01-06 , 5-12-11

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