BUSINESS REGISTRATION DIVISION PO BOX 29622 RALEIGH, NC 27626 - 0622 ( Revised August 2017 ) Form PLLC - 01 Instructions for Filing APPLICATION FOR CERTIFICATE OF AUTHORITY FOR A FOREIGN PROFESSIONAL LIMITED LIABILITY COMPANY (Form PLLC - 0 1 ) Item 1 Enter the complete name of the professional limited liability company ( P LLC) exactly as it appears in the records of the appropriate official in the state or country of formation. If the name cannot be used in North Carolina, enter the name (including an applicable professional limited liability company ending) that it wishes to use in North Carolina. Item 2 Enter the state or country of formation. Item 3 Enter the principal office address of the PLLC . Enter the complete street address of the principal office and the county in which it is located. If mail is not delivered to the street address of the principal off ice or if you prefer to receive mail at a P.O. Box or Drawer, enter the complete mailing address of the principal office. Item 4 in item 3. Item 5 Enter the complete street address of the P The registered office address must be located in North Carolina. Item 6 Enter the complete mailing address, in North Carolina, of the P ed agent, only if mail is not delivered to the street address above or if you prefer to receive mail at a P.O. Box or Drawer. Item 7 Enter the name of the registered agent. The registered agent must be a North Carolina resident, an existing domestic busin ess corporation, nonprofit corporation or limited liability company, or a foreign business corporation, nonprofit corporation or limited liability company authorized to transact business or conduct affairs in North Carolina. Item 8 Enter the names, titles, and usual business address of the current principal company officials of the LLC. Item 9 Attach a current Certificate of Existence or document of similar import with filing. The Certificate of Existence cannot be more than six months old. Item 10 If need ed, a statement indicating a copy of the resolution of its managers adopting a fictitious name is attached. Item 1 1 Enter the specific personal services to be rendered by the limited liability company . Item 12 Enter the name of at least one company offici al who is licensee of the applicable licensing board that regulates the professional service that the PLLC renders. Item 13 A certification from the applicable licensing board must be attached to the Articles of Organization. The certification must be an original unless the licensing board permits electronic certification . Item 1 4 The document will be effective on the date and at the time of filing, unless a delayed date or an effective time (on the date of filing) is specified. If a delayed effective dat e is specified without a time, it will be effective at 11:59:59 p.m. A delayed effective date may be specified up to and including the 90 th 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 limited liability company as it appears in Item 1. The signature of the principal company official of the LLC executing the document. The name and title of the above - signed principal company official. American LegalNet, Inc. www.FormsWorkFlow.com BUSINESS REGISTRATION DIVISION PO BOX 29622 RALEIGH, NC 27626 - 0622 ( Revised August 2017 ) Form PLLC - 01 State of North Carolina Department of the Secretary of State APPLICATION FOR CERTIFICATE OF AUTHORITY FOREIGN PROFESSIONAL LIMITED LIABILITY COMPANY Pursuant to Sections 57 D - 2 - 0 2 , 57 D - 7 - 0 3 , and 55B - 16 of the General Statutes of North Carolina, the undersigned limited liability company hereby applies for a Certificate of Authority to transact business in the State of North Carolina as a D - 2 - 0 2 and 55B - 16(b) and for that purpose submits the fo llowing: 1. The name of the limited liability company is ; and if the limited liability company name is unavailable for use in the State of North Carolina, the name the limited liability com pany wishes to use is 2. The state or country under whose laws the limited liability company was organized is: 3 . The street address of the principal office o f the limited liability company in the state or country under whose law it is organized is: Number and Street : City : State : Zip Code : 4 . The mailing address if different from the street address of the principal office of the limited liability company in the state or country under whos e law it is organized is: Number and Street or PO Box: City: State: Zip Code: 5 . The street ad dress and county of the registered office in the State of North Carolina is: Number and Street: City : State : NC Zip Code : Co unty 6 . The mailing address if different from the street address of the registere d office in the State of North Carolina is: Number and Street or PO Box: City: State: NC Zip Code: County 7 . The name of the registered agent in the State of North Carolina is: American LegalNet, Inc. www.FormsWorkFlow.com BUSINESS REGISTRATION DIVISION PO BOX 29622 RALEIGH, NC 27626 - 0622 ( Revised August 2017 ) Form PLLC - 01 APPLICATION FOR CERTIFICATE OF AUTHORITY Page 2 8 .The names, titles, and usual business addresses of the current company officials of the limited liability company are: (use attachment if necessary) Name and Title Business Address 9 .Attached is a certificate of existence (or document of similar import), duly authenticated by the secretary of state or other official having custody of limited liability company records in the state or country of organization. 1 0 .If the limited liability company is required to use a fictitious name in order to transact business in this State, a copy of the resolution of its managers adopting the fictitious name is attached. 1 1 .The personal services to be rendered by the limited liability company are 1 2 .With res pect to each professional service to be practiced through the limited liability company in this State, the name company officials who is a licensee of the licensing board which regulates such profession in this State is: (insert name here) 1 3 .Attached are certifications by the appropriate licensing boards that each individual set forth in Item 13 above is a - 2(2). 1 4 .This application will be effective upon filing, unless a delayed date and/or time is specified: This the day of , 20 . American LegalNet, Inc. www.FormsWorkFlow.com BUSINESS REGISTRATION DIVISION PO BOX 29622 RALEIGH, NC 27626 - 0622 ( Revised August 2017 ) Form PLLC - 01 APPLICATION FOR CERTIFICATE OF AUTHORITY Page 3 By executing this application on behalf of the applicant limited liability company, I certify under oath that the Sections 57 D - 2 - 0 2 and 55B - 16(b). Name of Limited Liability Company Signature of Company Official Type or Print Name & Title ( S ite of acknowledgment) This day of , 20, personally came before me, , Notary Public, , who, being by me duly sworn, says that he/she is of , a professional limited liability company , and that this application for certificate of authority was signed by him/her on behalf of the professional limited liability company by its authority duly given. And the said acknowledged the said writing to be the act and deed of said professional limited liability company. Witness my hand and official seal, this the day of , 20. (Official Seal) Notary Public My commission expires , 20. Notes: 1. Filing fee is $250. This document must be filed with the Secretary of State. s application. To determine whether a particular limited N.C.G.S. Sections 57D - 2 - 02 and 55B - 16(b), copies of which are attached. If the company does not meet the requirements r certificate of authority for a limited liability compa ny, available from this office. American LegalNet, Inc. www.FormsWorkFlow.com