Arkansas Secre t a ry of State Charlie Daniels State Capitol • Little Rock, Arkansas 72201-1094 501-682-3409 • www.sos.arkansas.gov Appointment of Agent to Receive Service of Process for Nonprofit Association (Please Type or Print) Name of Nonprofit Association: Federal tax Identification Number (if any): Address: Name and street address of person authorized as agent to receive service of process: I, , do hereby appoint the above-stated person as agent to receive service of process. I am authorized to manage the affairs of the nonprofit association. 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 I, receive service of process. Date , do hereby accept this appointment as agent to 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. Signature Filing Fee: $25.00 Date Rev. 4/06 American LegalNet, Inc. www.FormsWorkflow.com