State Form 38784 - Application For Certificate Of Authority Of A Foreign Corporation Page 2

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ARTICLE V - CORPORATE OFFICERS

List the names and business addresses of the officers of the Corporation.

Name

Title

Address (number and street, city, state, and ZIP code)

Please attach additional sheets if necessary.

ARTICLE VI - BOARD OF DIRECTORS

The names and business addresses of the Board of Directors of the Corporation are as follows:

By checking the box, the Signator(s) represents that the Corporation named in Article 1 is not required to have a Board of Directors in

its domicilary state.

Name

Address (number and street, city, state, and ZIP code)

Please attach additional sheets if necessary.

SIGNATURE

In witness whereof, the undersigned being the ____________________________________________________________ of said Corporation signs

(Title: Officer or Chairman or Board)

this Application for Certificate of Authority, and verifies subject to penalties of perjury, that the facts contained herein are true this _______________

day of __________________________________ , 20 __________ .

Signature

Printed name

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