Fill and Sign the Return to Work Plan Template Form

State of Utah This form must be type written or computer generated. Department of Commerce Division of Corporations & Commercial Code Application for Authority to Conduct Affairs for a Foreign Tribal Corporation Clear Form Print Form A certification of Good Standing/Existence from the Tribal Nation dated no earlier than ninety (90) days prior to filing with this office is attached to this application. Non-Refundable Processing Fee: [ ] Profit $70.00 1. Exact Corporate Name: [ ] Nonprofit $30.00 3. Date Incorporated: 2. A corporation from the tribal nation of: (usually perpetual) 4. The corporation’s period of duration is: 5. The address of the corporation's principal office is: ______________________________________________________________________________________________________________ Street Address City State Zip 6. Who/What is the name of the Registered Agent (Individual or Business Entity or Commercial Registered Agent)?: ________________________________________________________________________________________ is a commercial registered agent? The address must be listed if you have a non-commercial registered agent. See What instructions for further details. Address of the Registered Agent: ___________________________________________________________ Utah Street Address Required, PO Boxes can be listed after the Street Address City: State UT Zip: 7. If the name is not available in Utah the corporation shall use as it’s name: {Please refer to (U.C.A. 16-10a-1506)} 8. The corporation commenced or intends to commence business in Utah on: 9. The names and addresses of the corporation's officers and directors are: Position: President Name Address City State Zip Vice-President Secretary Treasurer Director Director Director Other 10. The business purposes to be pursued in Utah are: Under penalties of perjury, I declare that this application for Certificate of Authority has been examined by me and is, to the best of my knowledge and belief, true, correct and complete. Authorized Signer Signature: A corporate officer/director must sign here after the form is printed Optional Inclusion of Ownership Information: This information is not required. Is this a female owned business? Yes No Is this a minority owned business? Yes No Title: If yes, please specify: Select/Type the race of the owner here Under GRAMA {63-2-201}, all registration information maintained by the Division is classified as public record. For confidentiality purposes, you may use the business entity physical address rather than the residential or private address of any individual affiliated with the entity. Mailing/Faxing Information: www.corporations.utah.gov/contactus.html Division's Website: www.corporations.utah.gov