Arkansas Secre t a ry of State Charlie Daniels State Capitol • Little Rock, Arkansas 72201-1094 501-682-3409 • www.sos.arkansas.gov APPLICATION FOR VERIFICATION COMPANY Pursuant to the provisions of the Arkansas Electronic Records and Signatures Act of 1999, A.C.A. 25-31-101, the undersigned as the duly authorized and acting president, secretary, treasurer, superintendent or managing agent of the corporation named below for which this application is submitted, under oath, hereby states: 1. The name of the corporation is: The address of the corporation is: Street City State ZIP 2. Fictitious name to be used in Arkansas: 3. The state or foreign country under whose laws the corporation was incorporated is: 4. Date incorporated: 5. Period of Duration: 6. Please state any other states in which you are currently acting as a verification company and how long you have been acting as a verification company in each state: 7. Please deliver with the completed application a certificate of good-standing duly authorized by the Secretary of State or other official having custody of corporate records in the state or country under whose laws the corporation is incorporated. B. Please deliver with the completed application a copy of a surety bond in the amount of $250,000 made payable to the State of Arkansas. 9. Any corporation incorporated in any other state than Arkansas making application to act as a verification company in the State of Arkansas must obtain authority to do business in Arkansas prior to final approval of this application. Witness the hand and seal of the corporation executed under oath by the undersigned on this day of , . I understand that knowingly signing a false document with the intent to file with the Arkansas Secretary of State is a Class C misdemeanor and is punishable by a fine up to $100.00 and/or imprisonment up to 30 days. Authorizing Officer (Type or Print) Authorized Signature Title Rev. 4/06 American LegalNet, Inc. www.FormsWorkflow.com