NONFILING / NONQUALIFIED ENTITY STATEMENT
(FOR APPOINTMENT OF AGENT)
(PLEASE TYPE OR PRINT CLEARLY IN INK)
Note: The filing of a statement appointing an agent for service of process does not make the name of the entity filing the statement unavailable for use by another entity nor does it qualify or authorize an entity to transact business in this state.
1. Name of entity: _____________________________________________________________________________________ 2. Jurisdiction: ________________________________ Type of entity: ___________________________________________ 3. Name of registered agent 4. Street address of registered agent for service of process (In Arkansas) _________________________________________
Street Address Line 1
Street Address Line 2
City, State Zip
5. Mailing Address: ___________________________________________________________________________________
Mailing Address Line 1 Mailing Address Line 2 City, State Zip
I understand that knowingly signing a false document with the intent to file with the Arkansas Secretary of State is a Class C misdemeanor and is punishable by a fine up to $100.00 and/or imprisonment up to 30 days. Executed this ___________ day of _________________, _____________________.
Signature and Title of Authorized Individual
Typed or Printed Name of Authorized Individual
NFR-R Rev. 8/07