FORM NFP 113.15 (rev. Dec. 2003) APPLICATION FOR AUTHORITY TO CONDUCT AFFAIRS IN ILLINOIS (Foreign Corporations) General Not For Profit Corporation Act Secretary of State Department of Business Services 501 S. Second St., Rm. 350 Springfield, IL 62756 217-782-1834 www.cyberdriveillinois.com Print Reset Save Remit payment in the form of a cashier's check, certified check, money order or an Illinois attorney's or CPA's check payable to Secretary of State. ___________________________________ File #______________________________ 1. a. Corporate Name: _____________________________________________________________________________ b. Assumed Corporate Name (Complete only if the new corporate name is not available in this state.): ______________________________________________________________________________________________ By electing this assumed name, the Corporation hereby agrees NOT to use its corporate name in the transaction of business in Illinois. Form NFP 104.15 is attached. b. Date of Incorporation: __________________________________________________________________________ -------- Submit in duplicate -------- Type or Print clearly in black ink -------- Do not write above this line -------- Filing Fee: $50 Approved: ___________ 2. a. State or Country of Incorporation: _________________________________________________________________ c. Period of Duration:_____________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ First Name Number City Middle Name Street Last Name 3. a. Address of Principal Office, wherever located: _______________________________________________________ b. Address of Principal Office in Illinois: ______________________________________________________________ 4. Name and Address of Registered Agent and Registered Office in Illinois: Registered Agent: _______________________________________________________________________________ Suite # (P.O. Box alone is unacceptable) County Registered Office: _______________________________________________________________________________ ZIP Code 5. States and Countries in which Corporation is admitted or qualified to conduct affairs: __________________________ 6. Names and respective addresses of Corporation's officers and directors: President Director Director Director Street Address City State ZIP Registered Office _______________________________________________________________________________ Secretary If there are additional officers or more than three directors, please attach list. Printed by authority of the State of Illinois. January 2015 - 1 - C 160.15 American LegalNet, Inc. www.FormsWorkFlow.com 7. Purpose(s) for which the Corporation is organized and proposes to pursue in the conduct of affairs in this State: For more space, attach additional sheets of this size. 8. This application must be accompanied by an originally certified copy of the Articles of Incorporation and any amendments or mergers, duly authenticated within the last 90 days by the proper officer of the state or country wherein the corporation is incorporated. 9. The undersigned Corporation has caused this statement to be signed by a duly authorized officer who affirms, under penalties of perjury, that the facts stated herein are true and correct. All signatures must be in BLACK INK. Dated _______________________________ , _____ Month Day Year Any Authorized Officer's Signature Name and Title (type or print) ______________________________________ ______________________________________ ________________________________________________ Exact Name of Corporation A Corporation that is to function as a club, as defined in Section 1-3.24 of the Liquor Control Act of 1934, must insert in its purpose clause a statement that it will comply with the State and local laws and ordinances relating to alcoholic liquors. American LegalNet, Inc. www.FormsWorkFlow.com