11 F0009 OFFICE OF THE MISSISSIPPI SECRETARY OF STATE P.O. BOX 136, JACKSON, MS 39205-0136 (601) 359-1633 Application for Appointment of Registered Agent 1. Name of the Company Business email address________________________________ 2. It was organized under the laws of the state or other jurisdiction of 3. Name and Street Address of the Registered Agent and Registered Office are Name Physical Address P.O. Box City, State, ZIP5, ZIP4 4. The undersigned certifies that: 1) he/she has notified the above-named registered agent of this appointment; 2) he/she has provided the agent an address for the company, and; 3) the agent has agreed to serve as registered agent for this company. By: Signature (Please keep writing within blocks) Printed Name Title Mail completed form along with the $25 fee to SECRETARY OF STATE, PO BOX 136, JACKSON, MS 39205-0136. For assistance contact a customer service representative at (800) 256-3494. Visit our website at www.sos.ms.gov for forms and instructions. Rev. 2012 American LegalNet, Inc. www.FormsWorkFlow.com