Initial List Of Officers, Directors And Resident Agent (Profit) - Nevada Secretary Of State

FILE NUMBER

(PROFIT) INITIAL LIST OF OFFICERS, DIRECTORS AND RESIDENT AGENT OF

(Name of Corporation)

FOR THE FILING PERIOD OF

.TO

.

The corporation’s duly appointed resident agent in the State of Nevada upon whom process can be served is:

CHECK BOX IF YOU REQUIRE A FORM TO UPDATE YOUR RESIDENT AGENT INFORMATION

Important: Read instructions before completing and returning this form.

THE ABOVE SPACE IS FOR OFFICE USE ONLY

1. Print or type names and addresses, either residence or business, for all officers and directors. A President, Secretary, Treasurer, or equivalent of and all Directors must be named. Have an officer sign the

form.

FORM WILL BE RETURNED IF UNSIGNED

2. If there are additional directors attach a list of them to this form.

3. Return the completed form with the $125.00 filing fee. A $75.00 penalty must be added for failure to file this form by the last day of first month following the incorporation/initial registration with this office.

4. Make your check payable to the Secretary of State. Your cancelled check will constitute a certificate to transact business per NRS 78.155. To receive a certified copy, enclose an additional $30.00 and

appropriate instructions.

5. Return the completed form to: Secretary of State, 202 North Carson Street, Carson City, NV 89701-4201, (775) 684-5708.

6. Form must be in the possession of the Secretary of State on or before the last day of the first month following the incorporation/initial registration date. (Postmark date is not accepted as receipt date.) Forms

received after due date will be returned for additional fees and penalties.

FILING FEE: $125.00

LATE PENALTY: $75.00

This corporation is a publicly traded corporation.

The Central Index Key number is:

This corporation is not required to have a Central Index Key number.

NAME

TITLE(S)

PRESIDENT

(OR EQUIVALENT OF)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ADDRESS

CITY

ST

ZIP

NAME

TITLE(S)

SECRETARY

(OR EQUIVALENT OF)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ADDRESS

CITY

ST

ZIP

NAME

TITLE(S)

TREASURER

(OR EQUIVALENT OF)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ADDRESS

CITY

ST

ZIP

NAME

TITLE(S)

DIRECTOR

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ADDRESS

CITY

ST

ZIP

I declare, to the best of my knowledge under penalty of perjury, that the above mentioned entity has complied with the provisions of NRS 360.780 and acknowledge that pursuant to

NRS 239.330, it is a category C felony to knowingly offer any false or forged instrument for filing in the Office of the Secretary of State.

X Signature of Officer

Title

Date

Nevada Secretary of State Form INITIAL LIST-PROFIT 2003

Revised on: 09/24/03