Fill and Sign the Bir Form 0605 Latest Version

Wyoming Secretary of State State Capitol Building, Room 110 th 200 West 24 Street Cheyenne, WY 82002-0020 Ph. 307.777.7311 Fax 307.777.5339 Email: Business@wyo.gov For Office Use Only Foreign Nonprofit Corporation Application for Certificate of Authority Pursuant to W.S. 17-19-1503 of the Wyoming Nonprofit Corporation Act, the undersigned corporation hereby applies for a Certificate of Authority to transact business in the state of Wyoming, and for that purpose submits the following statement: 1. Name of the Nonprofit Corporation as incorporated: 2. Incorporated under the laws of: (State or country of incorporation) 3. Date of incorporation: (mm/dd/yyyy) 4. Period of duration: (This is referring to the length of time the nonprofit corporation intends to exist and not the length of time it has been in existence. The most common term used is “perpetual.” You may refer to your Articles of Incorporation or contact the Corporations Division in your state of incorporation for your period of duration.) 5. Mailing address of the nonprofit corporation: 6. Principal office address: 7. Name and physical address of its registered agent: (The registered agent may be an individual resident in Wyoming, a domestic or foreign entity authorized to transact business in Wyoming, having a business office identical with such registered office. The registered agent must have a physical address in Wyoming. A Post Office Box or Drop Box is not acceptable. If the registered office includes a suite number, it must be included in the registered office address.) FNP-CertificateAuthority – Revised 11/2012 8. Names and usual business addresses of its current officers and directors: Office Name Address President Vice President Secretary Treasurer Director Director Director 9. Does this corporation have members? Yes No 10. If this corporation had been incorporated under the laws of this state, would it be (Check appropriate choice.): a. Public benefit corporation b. Mutual benefit corporation c. Religious corporation 11. The corporation accepts the constitution of the state of Wyoming in compliance with the requirement of Article 10, Section 5 of the Wyoming Constitution. 12. For name availability purposes list the type of business the nonprofit corporation will be conducting: Signature: ___________________________________________ Date: (May be executed by Chairman of Board, President or another of its officers.) Print Name: Contact Person: Title: Daytime Phone Number: Email: FNP-CertificateAuthority – Revised 11/2012 (mm/dd/yyyy) Checklist Filing Fee: $25.00 Make check or money order payable to Wyoming Secretary of State. The completed application must be accompanied by an original certificate of existence/good standing, dated not more than sixty (60) days prior to filing in Wyoming, duly authenticated by the Secretary of State or other official having custody of corporate records in the state or country of formation. The Application must be accompanied by a written consent to appointment executed by the registered agent. For consistency the Secretary of State’s Office will only keep one version of the agent’s name on file. Please submit one originally signed document and one exact photocopy of the filing. Please review form prior to submitting to the Secretary of State to ensure all areas have been completed to avoid a delay in the processing of your documents. Other Requirements: • An annual report will be due annually on the first day of the anniversary month of formation. If not paid within sixty (60) days from the due date, the entity will be subject to dissolution/revocation. FNP-CertificateAuthority – Revised 11/2012 Wyoming Secretary of State State Capitol Building, Room 110 th 200 West 24 Street Cheyenne, WY 82002-0020 Ph. 307.777.7311 Fax 307.777.5339 Email: Business@wyo.gov Consent to Appointment by Registered Agent I, , registered office located at (name of registered agent) voluntarily consent to serve * (registered office physical address, city, state & zip) as the registered agent for (name of business entity) I hereby certify that I am in compliance with the requirements of W.S. 17-28-101 through W.S. 17-28-111. Signature:__________________________________________ Date: (Shall be executed by the registered agent.) Print Name: Daytime Phone: Title: (mm/dd/yyyy) Email: Registered Agent Mailing Address (if different than above): *If this is a new address, complete the following: Previous Registered Office(s): I hereby certify that: • After the changes are made, the street address of my registered office and business office will be identical. • This change affects every entity served by me and I have notified each entity of the registered office change. • I certify that the above information is correct and I am in compliance with the requirements of W.S. 17-28-101 through W.S. 17-28-111. Signature: __________________________________________ Date: (Shall be executed by the registered agent.) Checklist Submit one originally signed consent to appointment and one exact photocopy. RAConsent – Revised 12/11 (mm/dd/yyyy)