Free 18572.FH11 - Indiana

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APPLICATION FOR ADMISSION A FOREIGN CORPORATION

State Form 18572 (R2 / 10-06) Approved by State Board of Accounts, 2006 INDIANA DEPARTMENT OF FINANCIAL INSTITUTIONS

DATE OF ADMISSION (month, day, year) NAME OF THE DIRECTOR

(SEAL)

DO NOT WRITE ABOVE THIS LINE - FOR OFFICE USE ONLY
Please attach the following to this application: 1. A copy of Articles of Incorporation or Association; 2. A copy of the most recent quarterly Report of Condition and Income filed with the applicable Federal Regulatory Agency; and 3. A check in the amount of ninety dollars ($90.00), payable to the Secretary of State for their filing fee.

The undersigned makes application to the Indiana Department of Financial Institutions to obtain a certificate of admission to transact business as a Foreign Corporation in Indiana pursuant to I.C. 28-1-22-1 et seq. APPLICANT INFORMATION
Name of corporation Post office address of the principal office of the corporation outside of the State of Indiana City County State ZIP code

State or county where the corporation is incorporated

Date the corporation was established (month, day, year)

NATURE OF BUSINESS (Describe the nature of business that the foreign corporation intends to carry on in Indiana under its Articles of Incorporation or Association)

REGISTERED AGENT AND OFFICE INFORMATION
Name of the foreign corporations registered agent and registered office for service of legal process Post office address of the foreign corporations registered agent and registered office for service of legal process City County State ZIP code

AUTHORIZED SIGNATORY
Signature of President or Vice President Signature of Secretary or Cashier Date signed (month, day, year) Date signed (month, day, year)

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Effective 6/27/2001

STATE OF ______________________ ) ) SS: COUNTY OF ____________________ )

On ____________________________, ________, _________________________________________________ and ___________________________________________ personally appeared before me, a notary public, and after being sworn, stated that they are the duly authorized officers of ________________________________________________ Corporation and swear that the attached and foregoing statements are true and correct and further acknowledge the execution of the foregoing instrument.

Witness my hand and Notarial Seal this ___________ day of _________________________________

Signature

Name (please print legibly)

(SEAL)
County

Commission expiration date (month, day, year)

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Effective 6/27/2001