F0017 - Page 1 of 2 OFFICE OF THE MISSISSIPPI SECRETARY OF STATE P.O. BOX 136, JACKSON, MS 39205-0136 (601) 359-1333 Application for Registration of Corporate Name *0017-1-2* (For Foreign Corporations only) 1. Type of Corporation Profit Nonprofit 2. Name of Corporation 3. Corporation Postal Address Address City, State, ZIP5, ZIP4 - 4. Name and Street Address of the Applicant Name Physical Address P.O. Box City, State, ZIP5, ZIP4 - 5. Name elected to use in Mississippi 6. State or country of incorporation 7. Date incorporated or formed Rev. 02/96 >>>> 2 F0017 - Page 2 of 2 OFFICE OF THE MISSISSIPPI SECRETARY OF STATE P.O. BOX 136, JACKSON, MS 39205-0136 (601) 359-1333 Application for Registration of Corporate Name *0017-2-2* (For Foreign Corporations only) 8. Brief description of the nature of the activities in which it is engaged (Please keep writing within blocks) By: Signature Printed Name TitleRev. 02/96