11 F0002 - Page 1 of 3 OFFICE OF THE MISSISSIPPI SECRETARY OF STATE P.O. BOX 136, JACKSON, MS 39205-0136 (601) 359-1633 Application for Certificate of Authority The undersigned corporation, pursuant to Section 79-4-15.03 (if a profit corporation) or Section 79-11-367 (if a nonprofit corporation) of the Mississippi Code of 1972, hereby executes the following document and sets forth: 1. Type of Corporation Profit 2. Name of the Corporation Business Email Address _________________________________ Nonprofit 3. The future effective date is (Complete if applicable) 4. Its state or country of incorporation is 5. Street Address of the corporation's principal office City, State, ZIP5, ZIP4 6. Date of incorporation Period of duration 7. Name, Street and Mailing Address of the Registered Agent in Mississippi and Registered Office are Name Physical Address P.O. Box City, State, ZIP5, ZIP4 MS Rev. 5/2009 American LegalNet, Inc. www.FormsWorkFlow.com 11 F0002 - Page 2 of 3 OFFICE OF THE MISSISSIPPI SECRETARY OF STATE P.O. BOX 136, JACKSON, MS 39205-0136 (601) 359-1633 Application for Certificate of Authority 8. Officers Name Title Business Address City, State, ZIP5, ZIP4 Name Title Business Address City, State, ZIP5, ZIP4 Name Title Business Address City, State, ZIP5, ZIP4 9. Directors Name Title Business Address City, State, ZIP5, ZIP4 Name Title Rev. 5/2009 American LegalNet, Inc. www.FormsWorkFlow.com 11 F0002 - Page 3 of 3 OFFICE OF THE MISSISSIPPI SECRETARY OF STATE P.O. BOX 136, JACKSON, MS 39205-0136 (601) 359-1633 Application for Certificate of Authority Business Address City, State, ZIP5, ZIP4 Name Title Business Address City, State, ZIP5, ZIP4 10. FOR NONPROFIT ONLY (Check appropriate box) The corporation has members has no members. 11. Name elected to use in Mississippi is By: Signature (Please keep writing within blocks) Printed Name Title Rev. 5/2009 American LegalNet, Inc. www.FormsWorkFlow.com