Fill and Sign the State of Utah Department of Commerce Utah Division of Form

A certification of Good Standing/Existence from the State of Inco rporation 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 [ ] Nonprofit $ 30.00 1. Exact Corporate Name: 2. A corporation of the state of: 3. Date Incorporated: 4. The corporation’s period of duration is: (usually perpetual) 5. The address of the corporation's principal office is: ___________________ ________________________________ Street Address Line 1 ___________________ ________________________________ Street Address Line 2 City State Zip 6. Who/What is the name of the Registered Ag ent (Individual or Business Entity or Commercial Registered Agent)?: ____________________________________________________________________________________________ The address must be listed if you h ave a non-commercial registered agent. S ee 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 inte nds to commence business in Utah on: 9. The names and addresses of the corporation's officers and directors are: Position: Name Address City State Zip President 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 Authorit y has been examined by me and is, to the best of my knowledge and belief, true, correct and complete. Authorized Signer Signature: T it le : 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 If yes, please specify: 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 ra ther than the residential or private address of any individual affiliated with the e ntity. State of Utah Department of Commerce Division of Corporations & Commercial Code Application for Authority to Conduc t Affairs for a Foreign Corporation This form must be type written or computer generated. What is a commercial registered agent? Select/Type the race of the owner here Mailing/Faxing Information: www.corporations.utah.gov/contactus.html Division's Website: www.corporations.utah.gov