FORM BCA 4.25 (rev. Aug. 2014) APPLICATION FOR REGISTRATION, RENEWAL OR CANCELLATION OF FOREIGN CORPORATION NAME Business Corporation Act Secretary of State Department of Business Services 501 S. Second St., Rm. 350 Springfield, IL 62756 217-782-9520 217-782-6961 www.cyberdriveillinois.com Print Reset Save Payment must be made by check or money order payable to Secretary of State. 11. Corporation Name: ______________________________________________________________________________ 13. Date of Incorporation: ____________________________________________________________________________ 12. State or Country of Incorporation: __________________________________________________________________ -------- Submit in duplicate -------- Type or Print clearly in black ink -------- Do not write above this line -------- Filing fee $ _________________________ File # ___________________________ Approved: _________________ 14. Business in which Corporation is engaged: ___________________________________________________________ 15. Post Office Address of Corporation to which the Secretary of State may mail notices: _____________________________________________________________________________________________ _____________________________________________________________________________________________ 16. The corporation desires to register its corporate name pursuant to Section 4.25, and it is not transacting business in the State of Illinois at this time. 17. Attached to this application is a certificate setting forth that the corporation is in good standing under the laws of the state or country wherein it is organized, executed by the proper officer of the state or country wherein it is organized, and which certificate shall not be more than 90 days old. 18. Check appropriate box: o o o $50 registration fee $50 renewal fee $25 cancellation fee _____________________________________________________________________________________________ 19. Such registration or renewal of registration is effective from the date of filing by the Secretary of State until the first day of the 12th month following such date. 10. Cancellation is effective upon filing with the Secretary of State. 11. 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. Dated _______________________________ , _____ by ______________________________________ Any Authorized Officer's Signature Name and Title (type or print) Month & Day Year ________________________________________________ Exact Name of Corporation ______________________________________ Printed by authority of the State of Illinois. January 2015 -- 1 -- C 197.11 American LegalNet, Inc. www.FormsWorkFlow.com