Secretary Of The State Of Connecticut Application For Certificate Of Authority Foreign Corporation Page 3

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BUSINESS ADDRESS:
RESIDENCE ADDRESS:
(P.O.BOX UNACCEPTABLE)
(P.O.BOX UNACCEPTABLE)
ADDRESS:
ADDRESS:
CITY:
CITY:
STATE:
ZIP:
STATE:
ZIP:
ACCEPTANCE OF APPOINTMENT:
(SIGNATURE OF AGENT)
13. EXECUTION: (SUBJECT TO PENALTY OF FALSE STATEMENT)
DATED THIS
DAY
, 20
NAME OF SIGNATORY
CAPACITY/TITLE OF SIGNATORY
SIGNATURE
(print or type)
FORM CFAS-1-1.0
PAGE 3 OF 3
Rev. 8/2012

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