State Form 51575 - Articles Of Domestication Domestication Of A Foreign Corporation Into An Indiana Corporation - 2016 Page 3

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ARTICLE V: INCORPORATORS
The names and addresses of the incorporators of Corporation are as follows:
NAME
NUMBER AND STREET OR BUILDING
CITY
STATE
ZIP CODE
In Witness Whereof, the undersigned being an officer or other duly authorized representative executes these Articles of Domestication
and verifies, subject to penalties of perjury, that the statements contained herein are true,
this ____________________________ day of _________________________________, 20____________.
Required:
By checking the box, the Signator(s) represent(s) that the registered agent named in the application has consented to the appointment of registered
agent.
Signature
Printed name
Title
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