Form Tb-144 - Tobacco Product Distributor Appointment Of Agent For Service Of Process Page 2
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1
2In Witness Whereof, the undersigned has caused this appointment to be executed this
day of
A.D. ____________.
(Year)
Corporate Seal
(If a Corporation)
(Title)
(Title)
STATE OF
)
) SS:
COUNTY OF
)
BE IT REMEMBERED that on this
________________ day of __________________________________, __________, before me
day of
before me
(Year)
the undersigned, a notary public in and for said county and state, personally appeared
the undersigned, a notary public in and for said county and state, personally appeared
, who is (are) personally known to me to be the same person(s) who
who is (are) personally known to me to be the same person(s) who
executed the foregoing instrument, and duly acknowledged the execution of the same.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal the day and year last above written.
Notary Public in and for said County and State
SEAL
My Commission Expires
STATE OF
)
) SS:
COUNTY OF
)
BE IT REMEMBERED that on this
________________ day of __________________________________, __________, before me
day of
, before me
(Year)
the undersigned, a notary public in and for said county and state, personally appeared
the undersigned, a notary public in and for said county and state, personally appeared
of
of
,
a
a
corporation, and
corporation, and
,
of said corporation, each of whom is personally known to me to be respectively the
of said corporation, each of whom is personally known to me to be respectively the
and of said corporation and the same persons who executed the foregoing instrument in its behalf, and duly acknowledged the
execution of the same for and on behalf of and as the act and deed of said corporation.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal the day and year last above written.
Notary Public in and for said County and State
SEAL
My Commission Expires
st
th
Instructions: Submit this form along with the $15.00 filing fee to: Kansas Secretary of State, Memorial Hall, 1
Floor, 120 SW 10
Ave., Topeka KS 66612-1594. Any questions regarding the filing of this form you can call 785-296-4564.
Notice: There is a $25.00 service fee for all checks returned by your financial institution.
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