Free Microsoft Word - F0002 - Mississippi

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F0002 - Page 1 of 3

OFFICE OF THE MISSISSIPPI SECRETARY OF STATE
P.O. BOX 136, JACKSON, MS 39205-0136 (601) 359-1633

Application for Certificate of Authority
The undersigned corporation, pursuant to Section 79-4-15.03 (if a profit corporation) or Section 79-11-367 (if a nonprofit corporation) of the Mississippi Code of 1972, hereby executes the following document and sets forth:

1. Type of Corporation Profit 2. Name of the Corporation

Business Email Address _________________________________ Nonprofit

3. The future effective date is (Complete if applicable) 4. Its state or country of incorporation is

5. Street Address of the corporation's principal office

City, State, ZIP5, ZIP4 6. Date of incorporation Period of duration

7. Name, Street and Mailing Address of the Registered Agent in Mississippi and Registered Office are Name Physical Address P.O. Box City, State, ZIP5, ZIP4

MS

Rev. 5/2009

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F0002 - Page 2 of 3

OFFICE OF THE MISSISSIPPI SECRETARY OF STATE
P.O. BOX 136, JACKSON, MS 39205-0136 (601) 359-1633

Application for Certificate of Authority

8. Officers Name Title

Business Address City, State, ZIP5, ZIP4 Name Title

Business Address City, State, ZIP5, ZIP4 Name Title

Business Address City, State, ZIP5, ZIP4 9. Directors Name Title

Business Address City, State, ZIP5, ZIP4 Name Title

Rev. 5/2009

11

F0002 - Page 3 of 3

OFFICE OF THE MISSISSIPPI SECRETARY OF STATE
P.O. BOX 136, JACKSON, MS 39205-0136 (601) 359-1633

Application for Certificate of Authority

Business Address City, State, ZIP5, ZIP4 Name Title

Business Address City, State, ZIP5, ZIP4 10. FOR NONPROFIT ONLY (Check appropriate box) The corporation has members has no members.

11. Name elected to use in Mississippi is

By:

Signature

(Please keep writing within blocks)

Printed Name

Title

Rev. 5/2009