PAUL D. PATE Secretary of State State of Iowa APPLICATION FOR REGISTRATION OF CORPORATE NAME TO THE SECRETARY OF STATE OF THE STATE OF IOWA: The undersigned entity applies for the registration of its name, pursuant to the (check one) Iowa Business Corporation Act (profit corporation Iowa Code ch. 490). Revised Iowa Nonprofit Corporation Act (nonprofit corporation Iowa Code ch. 504). 1. The name of the business entity is ____________________________________________ 1A. [If applicable] The name to be registered if different than the name of the business entity because the real name is unavailable is _______________________________________________ 2. The state or foreign country in which the business entity is incorporated/formed is _____________________________________________________________________ 3. The date of incorporation/formation of the business entity is _________________________ 4. A brief description of the nature of the business in which the entity is engaged is _______________________________________________________________________ 5. A certificate of existence, or a document of similar import, from the state or country of incorporation/formation, accompanies this application. 6. The name and address of the applicant is: Name Address ________________________________________________________________ ______________________________________________________________ City, State, Zip __________________________________________________________ Signature ______________________________________________________________ Type or print name & title ___________________________________________________ 635_0118 1/15 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS NOTES: 1. The filing fee is $2.00 per month or part of a month, from the date the application is filed through December 31 of the calendar year in which the application is filed. Make checks payable to SECRETARY OF STATE. 2. The application is to be signed by the chairperson of the board of directors, the president, or another officer of the corporation. It must also state the person's name and the capacity in which the person is signed. 3. One copy of the document is to be delivered to the secretary of state for filing. 4. The name registration is effective through the end of the calendar year in which it is filed. 5. The information you provide will be open to public inspection under Iowa Code chapter 22.11. SECRETARY OF STATE Business Services Division Lucas Building, 1st Floor Des Moines, Iowa 50319 Phone: (515) 281-5204 FAX: (515) 242-5953 Website: sos.iowa.gov 635_0118 1/15 American LegalNet, Inc. www.FormsWorkFlow.com