BUSINESS REGISTRATION DIVISION P.O. BOX 29622 RALEIGH, NC 27626-0622 (Revised August 2017) (Form NA-01) STATE OF NORTH CAROLINA Department of the Secretary of State STATEMENT OF APPOINTMENT OF AGENT FOR A NONPROFIT ASSOCIATION Pursuant to 24759B-11 of the General Statutes of North Carolina, the undersigned Nonprofit Association submits the following for the purpose of designating an agent and the agent222s address in the State of North Carolina. 1.The name of the Nonprofit Association is: 2.The street address and county of the Nonprofit Association is: Number and Street: City, State, Zip Code: County: 3.The mailing address if different from the street address of the Nonprofit Association: 4.The street address in North Carolina of the Nonprofit Association222s Agent for service of process is: Number and Street: City, State, Zip Code: County: 5.The mailing address if different from the street address of the Nonprofit Association222s Agent for service of process is: 6.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*) 7.This statement will be effective upon filing, unless a date and/or time is specified: 8.This is the day of , 20. Name of Business Signature Type or Print Name and Title Notes: 1. Filing fee is $5.00. This statement must be filed with the Secretary of State. American LegalNet, Inc. www.FormsWorkFlow.com