Form Fpc - Foreign Application For Transfer Of Authority - The Commonwealth Of Massachusetts Page 2

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COMMONWEALTH OF MASSACHUSETTS
William Francis Galvin
Secretary of the Commonwealth
One Ashburton Place, Boston, Massachusetts 02108-1512
Foreign Application For
Transfer of Authority
(General Laws, Chapter 156D, Section 15.23; 950 CMR 113.53)
I hereby certify that upon examination of this foreign application for transfer of
authority, duly submitted to me, it appears that the provisions of the General Laws
relative thereto have been complied with, and I hereby approve said application;
and the fi ling fee in the amount of $ ___________________________________
having been paid, said application is deemed to have been fi led with me this
_____________ day of _____________
day of _____________
day of
, 20______ , at _______a.m./p.m.
time
Eff ective date: _____________________________________________________
(must be within 90 days of date submitted)
WILLIAM FRANCIS GALVIN
Secretary of the Commonwealth
Filing fee: Minimum $250.00
Examiner
TO BE FILLED IN BY CORPORATION
Name approval
Contact Information:
C
___________________________________________________________
M
___________________________________________________________
# A.R.
___________________________________________________________
Telephone: ___________________________________________________
Email: ______________________________________________________
Upon fi ling, a copy of this fi ling will be available at
If the document is rejected, a copy of the rejection sheet and rejected document will
be available in the rejected queue.

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