Form Mnpca-12a - Amended Application For Authority To Carry On Activities Page 2
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2DATED _________________________
*By ____________________________________________________
(signature of any duly authorized individual)
_____________________________________________________
(type or print name and capacity)
*This document MUST be signed by any duly authorized individual.
SUBMIT COMPLETED FORMS TO: CORPORATE EXAMINING SECTION, SECRETARY OF STATE,
101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101
FORM NO. MNPCA-12A
Rev. 4/16/2001
TEL. (207) 624-7740
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