New York State Department of State Division of Corporations, State Records and Uniform Commercial Code One Commerce Plaza, 99 Washington Avenue Albany, NY 12231 www.dos.state.ny.us APPLICATION FOR AUTHORITY OF (Insert name of Foreign Professional Service Limited Liability Company) Under Section 1306 of the Limited Liability Company Law FIRST: The name of the foreign professional service limited liability company is: If the name does not contain a required word or abbreviation pursuant to Section 1306(a)(1) of the Limited Liability Company Law, the following word or abbreviation is added to the name for its use in this state: SECOND: (A certificate of existence by an authorized officer of the jurisdiction of its formation must be attached to this The jurisdiction of organization of the foreign professional service limited liability company is: application.) The date of its formation is: THIRD: The foreign profession(s) of professional service limited liability company shall practice the in the State of New York. FOURTH: The foreign professional service limited liability company is authorized to practice such profession(s) in the jurisdiction of its formation. FIFTH: The city, incorporated village or town and the county within this state in which its office is to be located is: (A county in New York State must be stated. Please note that the limited liability company is not required to have an actual physical office in this state.) SIXTH: The Secretary of State is designated as agent of the foreign professional service limited liability company upon whom process against it may be served. The address within or without this state to which the Secretary of State shall mail a copy of any process served against him or her is: DOS-1369 (Rev. 5/08) -1- American LegalNet, Inc. www.FormsWorkflow.com SEVENTH: (Attach the appropriate certificate(s) from the licensing authority.) The name and address and, where applicable, the New York State license number of each professional within the foreign professional service limited liability company that are licensed to practice the profession or professions in New York State are: X (Signature) (Type or print name) (Title of signer) DOS-1369 (Rev. 5/08) -2- American LegalNet, Inc. www.FormsWorkflow.com APPLICATION FOR AUTHORITY OF (Insert name of Foreign Professional Service Limited Liability Company) Under Section 1306 of the Limited Liability Company Law Filed by: (Name) (Mailing address) (City, State and ZIP code) NOTE: This form was prepared by the New York State Department of State for filing an application for authority by a foreign professional service limited liability company. It does not contain all optional provisions under the law. You are not required to use this form. You may draft your own form or use forms available at legal supply stores. The Department of State recommends that legal documents be prepared under the guidance of an attorney. The certificate must be submitted with a $200 filing fee made payable to the Department of State. (For office use only) DOS-1369 (Rev. 5/08) -3- American LegalNet, Inc. www.FormsWorkflow.com