APPLICATION FOR CERTIFICATE OF AUTHORITY OF A FOREIGN NONPROFIT CORPORATION TO TRANSACT BUSINESS IN THE STATE OF INDIANA State Form 37035 (R8 / 4-12) Corporate Form No. 364-4 Approved by State Board of Accounts, 1995 CONNIE LAWSON SECRETARY OF STATE CORPORATIONS DIVISION 302 W. Washington St., Rm. E018 Indianapolis, IN 46204 T elephone: (317) 232-6576 INSTRUCTIONS: Use 8 1/2" x 11" white paper for attachments. Present original and one (1) copy to address in the upper right corner of this form. Please TYPE or PRINT. Please visit our office on the web at www.sos.in.gov. Applicant must submit a certificate of existence duly authenticated by the proper authority from corporation's domicilliary state. Indiana Code 23-17-26-1 et seq FILING FEE IS $30.00 The undersigned officer of ______________________________________________________________________________________ (hereinafter referred to as the "Corporation"), which exists pursuant to the provisions of ___________________________________ as (state or country) amended, desiring to effectuate the admittance of the Corporation to do business in the State of Indiana, certifies the following facts: ARTICLE I - NAME Name of Corporation (must be identical to name shown in Articles of Incorporation and Amendments thereto) ARTICLE II - REGISTERED OFFICE AND REGISTERED AGENT AND PRINCIPAL OFFICE Street address of its registered office in Indiana (number and street, city, and state) ZIP code Name of the registered agent at the office Street address of its principal office (number and street, city, and state) ZIP code ARTICLE III - DATE OF INCORPORATION AND DURATION OF EXISTENCE The date of incorporation in domicilliary state (month, day, year) Period of duration ARTICLE IV - TYPE OF CORPORATION (CHECK ONLY ONE) If the Corporation had been incorporated in Indiana, it would be a: public benefit corporation, which is organized for a public or charitable purpose; religious corporation, which is organized primarily or exclusively for religious purposes; or mutual benefit corporation (all others). (Continued on the reverse side) American LegalNet, Inc. www.FormsWorkFlow.com ARTICLE V - CORPORATE OFFICERS List the names and business addresses of the officers of the Corporation. Name Title Address (number and street, city, and state) ZIP code Name Title Address (number and street, city, and state) ZIP code Name Title Address (number and street, city, and state) ZIP code Please attach additional sheets if necessary. ARTICLE VI - BOARD OF DIRECTORS The names and business addresses of the Board of Directors of the Corporation are as follows: Name Address (number and street, city, and state) ZIP code Name Address (number and street, city, and state) ZIP code Name Address (number and street, city, and state) ZIP code Name Address (number and street, city, and state) ZIP code Name Address (number and street, city, and state) ZIP code Please attach additional sheets if necessary. ARTICLE VII Indicate whether the Corporation has members. Yes No members In witness whereof, the undersigned being the ____________________________________________________________ of said Corporation executes (Title) this Application for Certificate of Authority, and verifies subject to penalties of perjury, that the facts contained herein are true this __________________ day of __________________________________ , 20 __________ . Signature Printed name American LegalNet, Inc. www.FormsWorkFlow.com