BUSINESS REGISTRATION DIVISION P.O. BOX 29622 RALEIGH, NC 27626 - 0622 (Revised July, 2017) (Form BE - 05) STATE OF NORTH CAROLINA Department of the Secretary of State DESIGNATION OF REGISTERED OFFICE ADDRESS AND/OR REGISTERED AGENT Pursuant to 24755D-30 and 24755D-31 of the General Statutes of North Carolina, the undersigned entity submits the following for the purpose of designating a registered office and/or registered agent in the State of North Carolina. 1.The name of the entity is: 2.(Check if applicable). [ ] The entity currently has no registered office on file with the Secretary of State. 3.(Check if applicable). [ ] The mailing address of the registered office is not on file with the Secretary of State. 4.The street address and county of the entity222s designated registered office is: Number and Street: City: State: NC Zip Code: County: 5.The mailing address if different from the street address of the designated registered office is: Number and Street: City: State: NC Zip Code: County: 6.(Check if applicable). [ ] The entity currently has no registered agent on file with the Secretary of State. 7.The name of the designated registered agent and the designated registered agent222s written consent to the appointment appearsbelow : (Type or Print Name of New Agent) (Signature & Title*) 8.The address of the entity222s registered office and the address of the business office of its registered agent, as designated herein,will be identical. 9.This statement will be effective upon filing, unless a date and/or time is specified: 10.This is the day of , 20 . (Name of Entity) (Signature) (Type or Print Name and Title) NOTES: 1.Filing fee is $5.00. One executed statement must be filed with the Secretary of State. 2. This form is for use by entities that have not filed the name of a registered agent or address of a registered office with the Division. *Instead of signing here, the new registered agent may sign a separate written consent to the appointment, which must be attached to thisstatement. American LegalNet, Inc. www.FormsWorkFlow.com