Form Fbe - Certificate Of Authority (Foreign Business Entity)

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OMMONWEALTH OF

ENTUCKY

, S

LISON

UNDERGAN

RIMES

ECRETARY OF

TATE

______________________________________________________________________________________________________

Division of Business Filings

Certificate of Authority

FBE

Business Filings

(Foreign Business Entity)

PO Box 718, Frankfort, KY 40602

(502) 564-3490

Pursuant to the provisions of KRS 14A and KRS 271B, 273, 274,275, 362 and 386 the undersigned hereby applies for authority to transact business in Kentucky

on behalf of the entity named below and, for that purpose, submits the following statements:

1. The entity is a :

profit corporation (KRS 271B)

nonprofit corporation (KRS 273)

professional service corporation (KRS 274)

business trust (KRS 386).

limited liability company (KRS 275)

professional limited liability company (KRS 275)

limited partnership (KRS 362).

ltd cooperative assn. (KRS)

statutory trust

non-profit llc (KRS 275)

cooperative assn. (KRS)

2. The name of the entity is_______________________________________________________________________________________________________.

(The name must be identical to the name on record with the Secretary of State.)

3. The name of the entity to be used in Kentucky is (if applicable):_________________________________________________________________________.

(Only provide if "real name" is unavailable for use; otherwise, leave blank.)

4. The state or country under whose law the entity is organized is_________________________________________________________________________.

5. The date of organization is _______________________________________and the period of duration is ____________________________________.

(If left blank, the period of duration is considered perpetual.)

6. The mailing address of the entity’s principal office is

_______________________________________________________________ _________________________ _______________ _____________________.

Street Address

City

State

Zip Code

7. The street address of the entity’s registered office in Kentucky is

_______________________________________________________________ _________________________ _______________ _____________________.

Street Address (No P.O. Box Numbers)

City

State

Zip Code

and the name of the registered agent at that office is ___________________________________________________________________________________.

8. The names and business addresses of the entity’s representatives (secretary, officers and directors, managers, trustees or general partners):

_______________________________ ________________________________ ________________________ _______________ _____________________

Name

Street or P.O. Box

City

State

Zip Code

________________________________ _______________________________ ________________________ ________________ ____________________

Name

Street or P.O. Box

City

State

Zip Code

________________________________ _______________________________ ________________________ ________________ ____________________

Name

Street or P.O. Box

City

State

Zip Code

. If a professional service corporation, all the individual shareholders, not less than one half (1/2) of the directors, and all of the officers other than the secretary and treasurer are licensed in one or

more states or territories of the United States or District of Columbia to render a professional service described in the statement of purposes of the corporation.

10. I certify that, as of the date of filing this application, the above-named entity validly exists under the laws of the jurisdiction of its formation.

11. If a limited partnership, it elects to be a limited liability limited partnership. Check the box if applicable:

12. If a

limited

liability company, check box if manager-managed:

13. This application will be effective upon filing, unless a delayed effective date and/or time is provided.

The effective date or the delayed effective date cannot be prior to the date the application is filed. The date and/or time is ______________________________.

Please indicate the Kentucky county in which your business operates:

County: ___________________________________________.

To complete the following, please shade the box completely.

Please indicate the size of your business:

Please indicate whether any of the following make up more than fifty percent (50%) of your business ownership:

 Small (Fewer than 50 employees)

 Women-Owned

 Veteran Owned

 Minority Owned

 Large (50 or more employees)

Please indicate which of the following best describes your business:

 Agriculture