Form Cd-479 - Check List For Business Corporation Annual Report
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3CD-479
8-24-11
NAME OF BUSINESS CORPORATION:
SECRETARY OF STATE ID:
STATE OF FORMATION:
FISCAL YEAR ENDING:
I hereby certify that an annual report completed in its entirety has been submitted and the information requested below (required by NCGS
55-16-22) has not changed and is therefore complete.
SECTION A: REGISTERED AGENT'S INFORMATION
1.
NAME OF REGISTERED AGENT:
2.
AGENT:
SIGNATURE OF THE NEW REGISTERED
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3.
4.
REGISTERED OFFICE STREET ADDRESS & COUNTY
REGISTERED OFFICE MAILING ADDRESS
SECTION B: PRINCIPAL OFFICE INFORMATION
1.
DESCRIPTION OF NATURE OF BUSINESS:
2.
3.
PRINCIPAL OFFICE PHONE NUMBER:
PRINCIPAL OFFICE EMAIL:
4.
5.
PRINCIPAL OFFICE STREET ADDRESS & COUNTY
PRINCIPAL OFFICE MAILING ADDRESS
SECTION C: OFFICERS (Enter additional Officers in Section E.)
NAME:
NAME:
NAME:
TITLE:
TITLE:
TITLE:
ADDRESS:
ADDRESS:
ADDRESS:
SECTION D: CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a person/business entity.
SIGNATURE
DATE
Form must be signed by an officer listed under Section C of this form.
Print or Type Name of Officer
TITLE
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