Free c156ds501950c11320.indd - Massachusetts

D PC

The Commonwealth of Massachusetts
William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512

FORM MUST BE TYPED

(General Law, Chapter 156D, Section 5.01; 950 CMR 113.20)

Statement of Appointment of Registered Agent

FORM MUST BE TYPED

Exact name of corporation: ______________________________________________________________________________________

Registered office address: ________________________________________________________________________________________ (number, street, city or town, state, zip code) Appoints as registered agent: _____________________________________________________________________________________ (name of registered agent) The street address of the registered office of the corporation and the business address of the registered agent are identical as required by G.L., Chapter 156D, Section 5.02. This certificate is effective at the time and on the date approved by the Division, unless a later effective date not more than 90 days from the date of filing is specified: ________________________________________________________________________________________

Signed by: __________________________________________________________________________________________________ , (signature of authorized individual) ® Chairman of the board of directors, ® President, ® Other officer, ® Court-appointed fiduciary,

on this ________________day of ____________________________________ , __________ .

Consent of registered agent:

I, _______________________________________________________________________________________ , registered agent of the above corporation, consent to my appointment as registered agent pursuant to G.L. Chapter 156D, Section 5.02.*
*or attach registered agent's consent hereto.

P.C.

c156ds501950c11320 01/13/05

COMMONWEALTH OF MASSACHUSETTS
Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512

William Francis Galvin

(General Law, Chapter 156D, Section 5.01; 950 CMR 113.20)

Statement of Appointment of Registered Agent

I hereby certify that upon examination of this statement of appointment, duly submitted to me, it appears that the provisions of the General Laws relative to the organization of corporations have been complied with, and I hereby approve said statement; and the filing fee in the amount of $_____having been paid, said statement is deemed to have been filed with me this _____________ day of _____________, 20______ , at _______a.m./p.m. time Effective date: _________________________________________________ (must be within 90 days of date submitted)

WILLIAM FRANCIS GALVIN
Secretary of the Commonwealth

Filing fee: $25 for paper or fax filings. No fee if filed electronically.

TO BE FILLED IN BY CORPORATION
Contact Information: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Telephone: ___________________________________________________ Email: ______________________________________________________ Upon filing, a copy of this filing will be available at www.sec.state.ma.us/cor. If the document is rejected, a copy of the rejection sheet and rejected document will be available in the rejected queue.