Notice Of Entity Election Template
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1
2Ed Murray
Wyoming Secretary of State
2020 Carey Avenue, Suite 700
For Office Use Only
Cheyenne, WY 82002-0020
Ph. 307.777.7311
Fax 307.777.5339
Email:
Business@wyo.gov
Notice of Entity Election
Names and Addresses of Key Individuals
In accordance with W.S. 17-28-104(d)
(Print Name of Business Entity)
elects to provide the Wyoming Secretary of State with the names and addresses of its directors, officers, limited liability company managers,
managing partners, trustees or persons serving in a similar capacity. The names, addresses and titles are listed below.
1. Print Name:
Print Title:
Print Address:
2. Print Name:
Print Title:
Print Address:
3. Print Name:
Print Title:
Print Address:
4. Print Name:
Print Title:
Print Address:
5. Print Name:
Print Title:
Print Address:
6. Print Name:
Print Title:
Print Address:
If additional space is needed for names, addresses and titles, please attach an additional sheet.
I hereby certify that the information contained in this document is true and correct.
Date:
Signature: _____________________________________________________
(mm/dd/yyyy)
(Shall be executed by an authorized individual.)
Email:
Print Name:
Title:
Checklist
No Filing Fee
This information shall be kept current within 60 days of any change until the first annual report is filed and thereafter when the
annual report is due for filing.
Please submit one originally signed document.
Please review form prior to submitting to the Secretary of State to ensure all areas have been completed to avoid a delay in
the processing of your documents.
KeyIndividualsInformation – Updated October 2015
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