Form B-A-28 - Appointment Of Secretary Of State For Service Of Process
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1
2B-A-28
Appointment of Secretary of State
G.S. 105-113.24(c)
for Service of Process
Web
3-07
North Carolina Department of Revenue
_______________________________________________ a corporation incorporated or LLC organized and existing under the laws
(COMPANY Name)
of ____________________________________________; (or) ____________________________________________ having
(State)
(Name of PARTNERSHIP or INDIVIDUAL and D/B/A)
applied to the Secretary of Revenue to be licensed in compliance with the “Tobacco Products Tax Act,” as amended, does
hereby make, constitute and appoint the Secretary of State as its lawful attorney-in-fact upon whom any original process in
any action of legal proceeding may be served and does hereby agree that any original process against it so served, shall
be of the same force and effect as if served on it within this State, and that the authority so to do shall continue in force
irrevocably, so long as the applicant shall remain liable for any taxes, interest or penalty under the “Tobacco Products Tax
Act,” as amended, and does hereby set forth the following:
(a) The name of the applicant is ______________________________________________________________________
(Name of COMPANY, PARTNERSHIP or INDIVIDUAL)
(b) The address of the applicant is ____________________________________________________________________
(c) The names and addresses of its officers on the date of filing this statement with the Secretary of State of North Carolina are:
Pres. ________________________________________ Address __________________________________________
Vice Pres. ____________________________________ Address _________________________________________
Secy. ________________________________________ Address _________________________________________
Treas. _______________________________________ Address _________________________________________
Signed, sealed and delivered this
day of
,
(Month)
(Year)
INDIVIDUAL PRINCIPAL:
(SEAL)
(Signature)
(Print Name)
PARTNERSHIP PRINCIPAL:
(Print Name of Partnership)
BY:
(SEAL)
(Signature)
(Title)
(Print Name of Signer)
CORPORATION/LLC PRINCIPAL:
(Print Name of Corporation/LLC)
BY:
AFFIX SEAL OF
(Signature)
(Title)
CORP/LLC HERE
(Print Name of Signer)
Attest:
(Signature)
(Title)
(Print Name)
North Carolina Department of Revenue, Attention: Tobacco Products Unit, P.O. Box 871, Raleigh, NC 27602
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