APPLICATION FOR CERTIFICATE OF AUTHORITY OF A FOREIGN CORPORATION CONNIE LAWSON SECRETARY OF STATE CORPORATIONS DIVISION 302 W. Washington Street, Room E018 Indianapolis, Indiana 46204 Telephone: (317) 232-6576 State Form 38784 (R11 / 4-12) Corporate Form 112 Approved by State Board of Accounts, 1995 NOTES: 1. An Original Certificate of Existence duly authenticated by the proper authority from corporation's domiciliary state within the last sixty (60) days must be submitted with this application. 2. A Registered Agent with an Indiana street address (not a PO BOX) must be listed in ARTICLE III. INSTRUCTIONS: 1. 2. 3. 4. Indiana Code 23-1-49-1 et seq. 23-1-49-3 Filing Fee: $90.00 Use 8 1/2” x 11” white paper for attachments. Present original and one copy to address in the upper right corner of this form. Please TYPE or PRINT. Please visit our office on the web at www.sos.in.gov. APPLICATION FOR CERTIFICATE OF AUTHORITY OF A FOREIGN CORPORATION TO TRANSACT BUSINESS IN THE STATE OF INDIANA The undersigned officer of the above corporation which was formed as: A general business corporation A professional corporation desiring to effectuate the admittance of the Corporation to transact business in the State of Indiana, certifies the following facts: ARTICLE I: Name Name of Corporation ( Must be identical to name shown in Articles of Incorporation and Amendments thereto) ARTICLE II: Address of Corporation Address of the principal office of corporation (Number and street, city, state and ZIP code) ARTICLE III: Registered Office and Registered Agent Name of the Registered Agent of the corporation (cannot be the corporation itself) Indiana address of the registered office of corporation (Number and street, city; P.O. Box not accepted)) INDIANA ZIP code ARTICLE IV: Date and State of Incorporation and Duration of Existence State of incorporation Date of incorporation in domiciliary state (month, day, year): Expected period of duration listed in the Articles of Incorporation (perpetual, term of years or date certain e.g. December 31, 2050) ARTICLE V: Corporate Officers The names and business addresses of the officers of the Corporation: Name Title Address (Number, street, city, state and ZIP code) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com ARTICLE VI: Board of Directors The names and business addresses of the Board of Directors of the Corporation are as follows: Name Address (Number, street, city, state and ZIP code) In witness whereof, the undersigned being the (Title: officer or Chairman of Board) of said Corporation executes this Application for Certificate of Authority, and verifies subject to penalties of perjury, that the facts contained herein are true this of Signature , 20 day . Printed name Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com