BUSINESS REGISTRATION DIVISION P. O. BOX 29622 RALEIGH, NC 27626-0622 (Revised August 2017) Form N-09 State of North Carolina Department of the Secretary of State APPLICATION FOR CERTIFICATE OF AUTHORITY FOR NONPROFIT CORPORATION Pursuant to 24755A-15-03 of the General Statutes of North Carolina, the undersigned corporation hereby applies for a Certificate of Authority to conduct affairs in the State of North Carolina, and for that purpose submits the following: 1. The name of the corporation is and if that name is unavailable for use in the State of North Carolina, the name the corporation wishes to use is: 2. The state or country under whose laws the corporation was organized is: 3. The date of incorporation was ; its period of duration is: 4. The street address of the principal office of the corporation is: Number and Street City, State, Zip Code 5. The mailing address if different from the street address of the principal office of the corporation is: 6. The street address and county of the registered office in the State of North Carolina is: Number and Street City, State, Zip Code County: 7. The mailing address if different from the street address of the registered office in the State of North Carolina is: 8. The name of the registered agent in the State of North Carolina is: 9. The names and usual business addresses of the current officers of the corporation are: Name Title Business Address American LegalNet, Inc. www.FormsWorkFlow.com BUSINESS REGISTRATION DIVISION P. O. BOX 29622 RALEIGH, NC 27626-0622 (Revised August 2017) Form N-09 APPLICATION FOR CERTIFICATE OF AUTHORITY FOR NONPROFIT CORPORATION Page 2 10. (Check one of the following.) a. The corporation has members. b. The corporation does not have members. 11. Attached is a certificate of existence (or document of similar import), duly authenticated by the Secretary of State or other official having custody of corporate records in the state or country of incorporation. 12. If the corporation is required to use a fictitious name in order to conduct affairs in this State, a copy of the resolution of its board of directors, certified by its secretary, adopting the fictitious name is attached. 13. This application will be effective upon filing, unless a date and/or time is specified: This the day of , 20. Name of Corporation Signature Type or Print Name and Title Notes: 1. Filing fee is $125. 2. This document must be filed with the Secretary of State. American LegalNet, Inc. www.FormsWorkFlow.com BUSINESS REGISTRATION DIVISION P. O. BOX 29622 RALEIGH, NC 27626-0622 (Revised August 2017) Form N-09 Instructions for filing APPLICATION FOR CERTIFICATE OF AUTHORITY FOR NONPROFIT CORPORATION (Form N-09) Item 1 Enter the complete name of the corporation exactly as it appears in the records of the appropriate official in the state or country of organization. If that name cannot be used in North Carolina, enter the name that it wishes to use in North Carolina. Item 2 Enter the state or country of incorporation. Item 3 Enter the date of incorporation and the period of duration. Item 4 Enter the complete street address of the corporation222s principal office. Item 5 Enter the complete mailing address of the corporation222s principal office if different from the street address shown in Item 4. Item 6 Enter the complete street address of the corporation222s registered office and the county in which it is located. Item 7 Enter the complete mailing address of the corporation222s registered office if different from the street address shown in Item 6. Item 8 Enter the name of the registered agent. The registered agent must be a North Carolina resident, an existing domestic business or nonprofit corporation, or a foreign business or nonprofit corporation authorized to transact business or conduct affairs in North Carolina. Item 9 Enter the names, titles, and usual business addresses of the current officers of the corporation. Item 10-12 See form. Item 13 The document will be effective on the date and at the time of filing, unless a delayed date or an effective time (on the day of filing) is specified. If a delayed effective date is specified without a time, the document will be effective at 11:59:59 p.m. Raleigh, North Carolina time on the day specified. If a delayed effective date is specified with a time, the document will be effective on the day and at the time specified. A delayed effective date may be specified up to and including the 90th day after the day of filing. Date and Execution Enter the date the document was executed. In the blanks provided enter: The name of the corporation as it appears in item 1. The signature of the representative of the corporation executing the document (may be the presiding officer of the board of directors or any officer of the corporation). The name and title of the above-signed representative. American LegalNet, Inc. www.FormsWorkFlow.com