Form Cf-1 - Application For Certificate Of Authority - 2017 Page 3
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APPLICATION FOR CERTIFICATE OF AUTHORITY
11. Is the organization a "veteran-owned" organization?
Effective JULY 1, 2015, to meet the requirements for a “veteran-owned” organization, the entity filing the registration must
meet the following criteria per West Virginia Code §59-1-2a:
1. A “veteran” must be honorably discharged or under honorable conditions, and
2. A “veteran-owned business” means a business that meets one of the following criteria:
o Is at least fifty-one percent (51%) unconditionally owned by one or more veterans; or
o In the case of a publicly owned business, at least fifty-one percent (51%) of the stock is unconditionally owned by one or
more veterans.
Yes
CHECK BOX
(If "Yes," attach Form DD214)
indicating you have attached Veteran Affairs Form DD214
National Personnel Records Center
You may obtain a copy
No
Military Personnel Records
of your Veterans Affairs
1 Archives Drive
Form DD214 by
St. Louis, MO 63138
contacting:
Toll free: 1-86-NARA-NARA or 1-866-272-6272
Phone: 314-801-0800
Per WV Code
59-1-2(j)
effective July 1, 2015, the registration fee is waived for entities that meet the requirements as a "veteran-owned"
organization. See attached instructions to determine if the organization qualifies for this waiver. In addition, a "veteran-owned" entity will have
four (4) consecutive years of Annual Report fees waived AFTER the organization's initial formation [see WV Code 59-1-2a(m)].
12. The number of acres of land it holds or expects to hold in West Virginia is:
13. Contact and Signature Information* (See below Important Legal Notice Regarding Signature):
Phone:
a. Contact person to reach in case there is a problem with filing:
b. Print or type name of signer:
Title/Capacity of signer:
c. Signature:
Date:
*Important Legal Notice Regarding Signature: Per West Virginia Code §31D-1-129. Penalty for signing false document. Any person
who signs a document he or she knows is false in any material respect and knows that the document is to be delivered to the secretary of state for
filing is guilty of a misdemeanor and, upon conviction thereof, shall be fined not more than one thousand dollars or confined in the county or
regional jail not more than one year, or both.
Important Note: This form is a public document. Please do NOT provide any personal identifiable information on this form such as social
security number, bank account numbers, credit card numbers, tax identification or driver's license numbers.
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Form CF-1
Issued by the Office of the Secretary of State
Rev. 01/17
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