Free ApptAgenttoReceiveServ. - Arkansas

Arkansas Secre t a ry of State
Charlie Daniels
State Capitol · Little Rock, Arkansas 72201-1094 501-682-3409 · www.sos.arkansas.gov

Business & Commercial Services, 250 Victory Building, 1401 W. Capitol, Little Rock

Appointment of Agent to Receive Service of Process for Nonprofit Association
(Please Type or Print)

Name of Nonprofit Association: Federal tax Identification Number (if any): Address:

Name and street address of person authorized as agent to receive service of process:

I, , do hereby appoint the above-stated person as agent to receive service of process. I am authorized to manage the affairs of the nonprofit association.
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.

Authorizing Officer (Type or Print) Authorized Signature Date

I, receive service of process.

, do hereby accept this appointment as agent to

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.

Signature

Date

Filing Fee: $25.00 payable to Arkansas Secretary of State

Rev. 4/06