Commercial Registered Agent Registration Statement - Nevada Secretary Of State
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1*180104*
BARBARA K. CEGAVSKE
Secretary of State
*180104*
202 North Carson Street
Carson City, Nevada 89701-4201
(775) 684-5708
Website:
Commercial Registered Agent
Registration Statement
(PURSUANT TO NRS 77.320)
Instructions: An individual or entity transacting business as a
Registered Agent in this state for 10 or more business entities must
register with the Secretary of State as a Commercial Registered Agent.
All sections must be completed or the filing will be rejected.
1. Person registering as a commercial registered agent:
ABOVE SPACE IS FOR OFFICE USE ONLY
Legal Name of Individual:
USE BLACK INK ONLY - DO NOT HIGHLIGHT
or
Legal Name of Entity:
2. Entity Type:
3. Nevada Business ID#:
4. Jurisdiction of Organization:
5. All DBAs, fictitious firm names and websites or domains by which this commercial registered agent will do
business (add pages, if necessary):
6. The above listed person is in the business of serving as a commercial registered agent in Nevada. The business
address of the person in this State to which service of process and other notice and documents being served on or
sent to entities represented by it may be delivered is:
Nevada
Street Address
City
Zip Code
Nevada
Mailing Address (only if different from above)
City
Zip Code
7. Email address where electronic notices may be sent:
8. Individual who has the authority to act on behalf of the commercial registered agent:
Name:
Telephone:
Address:
Street Address
City
State
Zip Code
9. Required Statement: The person registering as a commercial registered agent or each director, officer or
managing agent of a commercial registered agent has not been convicted of a felony, and if convicted of a felony,
the individual has had his or her civil right restored. The registered agent has not had his or her ability to serve as a
registered agent or a director, officer or managing agent of a registered agent denied or revoked by appropriate
authority of this state or another state or enjoined by a court of competent jurisdiction from serving as a registered
agent because the individual engaged in conduct as a registered agent that was intended to or likely deceive or
defraud the public.
10. Signature: I declare, to the best of my knowledge under penalty of perjury, that the information contained in this
document is correct and acknowledge that pursuant to NRS 239.330, it is a category C felony to knowingly offer any
false or forged instrument for filing in the Office of the Secretary of State.
First Name of Signer (Print)
Middle Initial Last Name of Signer
X
Date
Authorized Signature of Individual or On Behalf of Entity
Nevada Secretary of State Form CRA Registration
Revised: 1-5-15
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