Form Sll-902 - Application For Certificate Of Authority
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1COMMONWEALTH OF KENTUCKY
TREY GRAYSON
SECRETARY OF STATE
APPLICATION FOR CERTIFICATE OF AUTHORITY
Pursuant to the provisions of KRS Chapter 275, the undersigned hereby applies for authority to transact business in Kentucky
on behalf of the limited liability company named below and for that purpose submits the following statements:
1.The company is
a limited liability company (LLC).
a professional limited liability company (PLLC).
2.The name of the limited liability company is
__________________________________________________________________________________________________.
3.The name of the limited liability company to be used in Kentucky is
__________________________________________________________________________________________________.
(if "real name" is unavailable for use)
4. _________________________________ is the state or country of organization.
5._________________________________ is the date of organization and, if the limited liability company has a specific date
of dissolution, the latest date upon which the limited liability company is to dissolve is _____________________________.
6.The street address of the office required to be maintained in the state of formation or, if not so required, the principal
office address is
__________________________________________________________________________________________________.
Street
City
State
Zip Code
7.The names and usual business addresses of the current managers, if any, are as follows:
___________________________________________ ______________________________________________________
Name
Address
___________________________________________ ______________________________________________________
Name
Address
(Attach a continuation, if necessary)
8.The street address of the registered office in Kentucky is
__________________________________________________________________________________________________
Street
City
State
Zip Code
and the name of the registered agent at that office is
__________________________________________________________________________________________________.
9.This application will be effective upon filing, unless a delayed effective date and/or time is specified:
________________________________________
(Delayed effective date and/or time)
I certify that, as of the date of filing this application, the above-named limited liability company validly exists as a limited liability
company under the laws of the jurisdiction of its formation.
_____________________________________________
Signature
_____________________________________________
Type or Print Name & Title
Date:_______________________________, 20_______
I, ______________________________________________________________, consent to serve as the registered agent on behalf of the limited liability
company.
Type or print name of registered agent
_______________________________________________________________
Signature of Registered Agent
______________________________________________________________
Type or Print Name & Title
SLL-902 (2/98)
(See attached sheet for instructions)
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