COMMONWEALTH OF KENTUCKY ALISON LUNDERGAN GRIMES, SECRETARY OF STATE ______________________________________________________________________________________________________ Division of Business Filings Business Filings PO Box 718 Frankfort, KY 40602 (502) 564-3490 www.sos.ky.gov Certificate of Authority (Foreign Business Entity) FBE Pursuant to the provisions of KRS 14A and KRS 271B, 273, 274,275, 362 and 386 the undersigned hereby applies for authority to transact business in Kentucky on behalf of the entity named below and, for that purpose, submits the following statements: 1. The entity is a : profit corporation (KRS 271B). business trust (KRS 386). limited partnership (KRS 362). 2. The name of the entity is_________________________________________________________________________________________________________. (The name must be identical to the name on record with the Secretary of State.) nonprofit corporation (KRS 273). limited liability company (KRS 275). professional service corporation (KRS 274). professional limited liability company (KRS 275). 3. The name of the entity to be used in Kentucky is (if applicable):__________________________________________________________________________. (Only provide if "real name" is unavailable for use; otherwise, leave blank.) 4. The state or country under whose law the entity is organized is___________________________________________________________________________. 5. The date of organization is _______________________________________and the period of duration is _________________________________________. (If left blank, the period of duration is considered perpetual.) 6. The mailing address of the entity's principal office is _______________________________________________________________ _________________________ _______________ _____________________. Street Address City State Zip Code 7. The street address of the entity's registered office in Kentucky is _______________________________________________________________ _________________________ _______________ _____________________. Street Address (No P.O. Box Numbers) City State Zip Code and the name of the registered agent at that office is _____________________________________________________________________________________. 8. The names and business addresses of the entity's representatives (secretary, officers and directors, managers, trustees or general partners): _______________________________ ________________________________ ________________________ _______________ ______________________ Name Street or P.O. Box City State Zip Code ________________________________ _______________________________ ________________________ ________________ ____________________ Name Street or P.O. Box City State Zip Code ________________________________ _______________________________ ________________________ ________________ ____________________ Name Street or P.O. Box City State Zip Code 9. If a professional service corporation, all the individual shareholders, not less than one half (1/2) of the directors, and all of the officers other than the secretary and treasurer are licensed in one or more states or territories of the United States or District of Columbia to render a professional service described in the statement of purposes of the corporation. 10. I certify that, as of the date of filing this application, the above-named entity validly exists under the laws of the jurisdiction of its formation. 11. If a limited partnership, it elects to be a limited liability limited partnership. Check the box if applicable: 12. If a limited liability company, check box if manager-managed: 13. This application will be effective upon filing, unless a delayed effective date and/or time is provided. The effective date or the delayed effective date cannot be prior to the date the application is filed. The date and/or time is ______________________________. (Delayed effective date and/or time) _____________________________________________ _______________________________ _________________________ Signature of Authorized Representative Printed Name & Title Date I, _________________________________________________________, consent to serve as the registered agent on behalf of the business entity. Type/Print Name of Registered Agent ______________________________________ _________________________ _________________________ ____________ Signature of Registered Agent Printed Name Title Date (09/15) American LegalNet, Inc. www.FormsWorkFlow.com FILING INSTRUCTIONS APPLICATION FOR CERTIFICATE OF AUTHORITY FOR A FOREIGN BUSINESS ENTITY TYPE OF FORMATION The corporation must indicate if it is a corporation (KRS 271B), a nonprofit corporation (KRS 273), a professional service corporation (KRS 274), a business trust (KRS 386), a limited liability company (KRS 275) or a limited partnership (KRS 362) by checking the appropriate box. NAME The business entity name must be exactly as written in the home state and comply with the ending requirements of KRS 14A.3-010. DATE OF ORGANIZATION AND DURATION The date of organization is the date the business entity filed with the secretary of state or other official having custody of corporate records. The period of duration of the business entity is that period which is stated in the organization filing. (May be perpetual or a total number of years.) PRINCIPAL OFFICE ADDRESS The principal office is the office (in or out of this state) so designated in writing with the Office of the Secretary of State where the principal designated office of the business entity is located. This address is where all correspondence from the Office of the Secretary of State (See Document Delivery) will be mailed. REGISTERED OFFICE AND REGISTERED AGENT The registered office of the business entity must be in Kentucky and maintain a street address (a PO Box is insufficient for the registered office address). In order to transact business in Kentucky, the registered agent shall be an individual resident of Kentucky, a Kentucky domestic corporation, a Kentucky domestic non-corporation, a Kentucky domestic limited liability company, a foreign corporation, a foreign non-corporation or a foreign limited liability company authorized to transact business in Kentucky. The registered agent is the individual or business designated to receive service of process in the event the business is party to a legal action. The company seeking formation shall not act as its own registered agent. CONSENT OF REGISTERED AGENT