Secretary of State Office 500 E Capitol Ave Pierre, SD 57501 (605)773-4845
ANNUAL REPORT
Foreign
Please Type or Print Clearly in Ink
FILE DATE
____________________
RECEIPT NO ___________________
FILING FEE: $50 Make check payable to SECRETARY OF STATE
1. Corporate Name and Mailing Address:
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Search for Corporate ID, Name and Agent
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Telephone # ____________________ FAX # _______________________
FILING DATE: Due during the month the Certificate of Authority was issued, and delinquent after the last day of the following month.
2. The jurisdiction under whose law it is formed ___________________________________________________________ 3. The address of the principal executive office in or out of the State of South Dakota. ______________________________________________________________________________________________
Street Address City State ZIP+4
______________________________________________________________________________________________
Mailing Address (Optional) City State ZIP+4
4. The name of the South Dakota Registered Agent _______________________________________________________ ______________________________________________________________________________________________
Street Address (Required to be a South Dakota Address) City State ZIP+4
______________________________________________________________________________________________
Mailing Address (Optional Required to be a South Dakota Address) City State ZIP+4
5. The names and business addresses of its principal officers and directors. Please place a check mark next to the name if the principal officer serves as a director. _____________________________________________________________________________________________
President Street Address City State ZIP+4
_____________________________________________________________________________________________
Vice President Street Address City State ZIP+4
_____________________________________________________________________________________________
Secretary Street Address City State ZIP+4
_____________________________________________________________________________________________
Treasurer Street Address City State ZIP+4
_____________________________________________________________________________________________
Director Street Address City State ZIP+4
_____________________________________________________________________________________________
Director Street Address City State ZIP+4
Dated ____________________________
______________________________________________
(Signature of an authorized officer)
______________________________________________
(Printed Name)
______________________________________________
(Title)
annualreportforeign July 2009