FIFTH:
Its jurisdiction of incorporation is _________________________________ (state or country) and the date of
incorporation is ______________________.
SIXTH:
Address of the principal office, wherever located, is:
_______________________________________________________________________________________________
(street, city, state and zip code)
_______________________________________________________________________________________________
(mailing address if different from above)
SEVENTH:
The names and usual business addresses of its current directors and officers: (Attach additional pages, if necessary.)
______________________________________________ Street ___________________________________________
(type or print name and capacity)
(street or mailing address)
___________________________________________
(city, state and zip code)
______________________________________________ Street ___________________________________________
(type or print name and capacity)
(street or mailing address)
__________________________________________
(city, state and zip code)
______________________________________________ Street ___________________________________________
(type or print name and capacity)
(street or mailing address)
__________________________________________
(city, state and zip code)
EIGHTH:
This application must be accompanied by a certificate of existence or a document of similar import duly authenticated
by the Secretary of State or other official having custody of corporate records in the state or country under whose law the
foreign corporation is incorporated. The certificate of existence must have been made not more than 90 days prior to the
delivery of this application for filing.
Dated __________________________
*By
___________________________________________________
(original signature of an officer)
___________________________________________________
(type or print name and capacity/title)
**The professional corporation name as used in the State of Maine must contain one of the following: “chartered,” “professional
corporation,” “professional association” or “service corporation” or the abbreviation “P.C.,” “P.A.” or “S.C.”. If the legal name in your
jurisdiction doesn’t require the use of these words, you must file a fictitious name. (See item first)
*This document MUST be originally signed by any duly authorized officer.
(13-C MRSA
§121.5)
Please remit your payment made payable to the Maine Secretary of State.
Submit completed form to:
Secretary of State
Division of Corporations, UCC and Commissions
101 State House Station
Augusta, ME 04333-0101
Telephone Inquiries: (207) 624-7752
Email Inquiries:
CEC.Corporations@Maine.gov
Form No. MBCA-12 (2 of 2) Rev. 10/19/2016
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