State of Connecticut Form TPM-4 Notice of Appointment of Registered Agent and Registered Agent's Statement (Rev. 03/16) Check the appropriate box: Complete this form in black or blue ink only. Nonparticipating Manufacturer (NPM) Importer Enter the name of NPM importing for: ____________________________________ Sign, date, and return original to: Office of the Attorney General Finance Department PO Box 120 Hartford CT 06141-0120 , _________________________________________________________________________ The undersigned NPM or Importer, hereby appoints _____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________ as its registered agent. Said registered agent is authorized to receive service of process on behalf of the NPM or Importer. The NPM or Importer agrees to do the following: 1. 2. Provide notice to the Office of the Attorney General of the State of Connecticut (Attorney General) at least 30 calendar days prior to termination of the authority of the registered agent; and Provide proof to the satisfaction of the Attorney General of the appointment of a new agent at least five calendar days prior to the termination of the existing agent appointment. The NPM or Importer further agrees that if the agent terminates its agency appointment, the undersigned will provide notice to the Attorney General of the termination within five calendar days and will include proof to the Attorney General of the appointment of a new agent. I hereby certify and declare that all of the statements and information contained in this Notice of Appointment, including but not limited to any accompanying statements or attachments, are true and complete and that I am a person authorized to bind the NPM or Importer making this Notice of Appointment either under the laws of Connecticut or of the jurisdiction where the manufacturer resides or is organized. The failure to file this form is a basis for removal of the undersigned NPM or Importer and its brand families from the Connecticut Directory. This Notice of Appointment must be signed and dated in the presence of a notary public. Signature of authorized representative for NPM or Importer: ________________________________________________________________________ Authorized representative (print name) ____________________________________________ Title: _______________________________________ Principal place of business (physical address): ___________________________________________________________________________________ _________________________________________________________________________________________________________________________ State of _________________________________ County of _______________________________ Country of ______________________________ On ___________________________________________________________________ , before me, ______________________________________________________________________ , personally appeared _______________________________________________________________________ , personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument and acknowledged to me that he or she executed the same in his or her authorized capacity, and that by his or her signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument. WITNESS my hand and official seal. Signature ______________________________________________________________________________________________ My Commission expires: ____________________________________________________________________________ Registered agents must complete and sign the statement on the back of this form. American LegalNet, Inc. www.FormsWorkFlow.com Name and address of Registered Agent: Name Telephone Fax number Address must be within the State of Connecticut. Address (number and street, PO box) City State ZIP code CT Email address: I consent to serve as the Registered Agent in the State of Connecticut for the above-named NPM or Importer, pursuant to Conn. Gen. Stat. §4-28n. I understand it will be my responsibility to receive Service of Process on behalf of the NPM or Importer; to forward mail to the NPM or Importer; and to immediately notify the Office of the Attorney General if I resign or change the office address of the Registered Agent. This Notice of Appointment must be signed and dated in the presence of a notary public. Signature: ___________________________________________________________________ Date: _______________________________________ Print name: __________________________________________________________________ Title: _______________________________________ State of _________________________________ County of _______________________________ Country of ______________________________ On ___________________________________________________________________ , before me, ______________________________________________________________________ , personally appeared _______________________________________________________________________ , personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument and acknowledged to me that he or she executed the same in his or her authorized capacity, and that by his or her signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument. WITNESS my hand and official seal. Signature ______________________________________________________________________________________________ My Commission expires: ____________________________________________________________________________ Form TPM-4 Back (Rev. 03/16) American LegalNet, Inc. www.FormsWorkFlow.com