Form 47-269 Mail this Application To: Secretary of State P. O. Box 136 Jackson, Mississippi 39205 Application for Registration with the Secretary of the State of Mississippi, under the provisions of Mississippi Code, Annotated, Section 67-1-47 (1972): FIRST, The name of said Company is SECOND, The State of incorporation and the complete address of its general office: THIRD, If not incorporated, set forth the names and addresses of the partners or individuals comprising said Company FOURTH, Names and complete mailing addresses of all local agents of the Company: FIFTH, The name and address of the agent for the service of process within the State of Mississippi: Given under the signature and seal of said Company at , on this the day of , A.D., 20 , Name of Company By: American LegalNet, Inc. www.FormsWorkflow.com