Free Communications Contact And Key Individuals - Wyoming

Wyoming Secretary of State
State Capitol Building, Room 110 200 West 24th Street Cheyenne, WY 82002-0020 Ph. 307.777.7311 Fax 307.777.5339 Email: [email protected]

For Office Use Only

Notice of Entity Election Names and Addresses of Key Individuals
In accordance with W.S. 17-28-104(d) (Print Name of Business Entity) elects to provide the Wyoming Secretary of State with the names and addresses of its directors, officers, limited liability company managers, managing partners, trustees or persons serving in a similar capacity. The names, addresses and titles are listed below. 1. Print Name: Print Address: 2. Print Name: Print Address: 3. Print Name: Print Address: 4. Print Name: Print Address: 5. Print Name: Print Address: 6. Print Name: Print Address: If additional space is needed for names, addresses and titles, please attach an additional sheet. I hereby certify that the information contained in this document is true and correct. Date: (mm/dd/yyyy) Signature: _____________________________________________________ (Shall be executed by an authorized individual.) Print Name: Title: Checklist No Filing Fee This information shall be kept current within 60 days of any change until the first annual report is filed and thereafter when the annual report is due for filing. Please submit one originally signed document and one exact photocopy of the filing. Please review form prior to submitting to the Secretary of State to ensure all areas have been completed to avoid a delay in the processing of your documents. KeyIndividualsInformation ­ 1/1/2009 Print Title: Print Title: Print Title: Print Title: Print Title: Print Title:

Wyoming Secretary of State
State Capitol Building, Room 110 200 West 24th Street Cheyenne, WY 82002-0020 Ph. 307.777.7311 Fax 307.777.5339 Email: [email protected]

For Office Use Only

Notice of Entity Election Communications Contact Person
In accordance with W.S. 17-28-104(d)
(Print Name of Business Entity)

elects to provide the Wyoming Secretary of State with the name, business address and phone number of a natural person who is an officer, director, employee or designated agent authorized to be the communications contact person for this business entity. 1. Name and title of the natural person authorized to be the communications contact person: Print Name:

Print Title:

2. Business Address: Print Address:

Print City, State and Zip Code:

3. Daytime Phone Number:

4. I hereby certify that the information provided above is true and correct. Date:
(mm/dd/yyyy)

Signature: __________________________________________
(Shall be executed by an authorized individual.)

Print Name: Title: Checklist No Filing Fee The information listed on this form shall be kept current within 60 days of any change. Please submit one originally signed document and one exact photocopy of the filing. Please review form prior to submitting to the Secretary of State to ensure all areas have been completed to avoid a delay in the processing of your documents.
CommunicationsContact ­ 1/1/2009