STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS Office of the Secretary of State Corporations Division 148 W. River Street Providence, Rhode Island 02904-2615 DESIGNATION OF AGENT FOR NONRESIDENT OWNERS OF AMUSEMENTS ________ Pursuant to the provisions of Section 23-34.1-14 of the General Laws, 1956, as amended, the undersigned owner of amusements, who is not a resident of the State of Rhode Island, submits the following statement for the purpose of appointing the Secretary of State of the State of Rhode Island and his or her successors in office to be his or her attorney, upon whom all process in any action or proceeding against him or her may be served. 1. The name of the nonresident owner is 2. The address of the nonresident owner to which the secretary of state shall mail a copy of any process against the owner that may be served on him or her is 3. The owner named in item 1 above agrees that any process against him or her which is served on the secretary of state shall be of the same legal force and validity as if served on him or her as such owner, and that such appointment shall continue in force as long as any liability remains outstanding against the owner in this state. Date: Signature of Owner STATE OF COUNTY OF In ____________________________, on this ________ day of _________________________, _______, personally appeared before me ______________________________________________________________, an owner of amusements, who, under oath, verified that the information contained in this document is true and accurate. Notary Public My Commission Expires: Form No. 23-34.1-14 Revised: 12/05 American LegalNet, Inc. www.FormsWorkflow.com