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Fund-Raising Counsel Application For Registration Form - Office Of The Attorney General Page 5

DUSTIN McDANIEL

A T T O R N E Y G E N E R A L

OFFICE OF THE ATTORNEY GENERAL

3 2 3 C E N T E R S T R E E T , S u i t e 2 0 0

LITTLE ROCK, AR 72201-2610 (501) 682-2007

CON S ENT FOR SERVICE

FU ND-RAISING COUNSEL

________________________________________________________ , Fund-Raising Counsel, hereby appoint(s) the

Attorney General of the State of Arkansas as agent for service in case of any and all lawsuits, proceedings and actions

growing out of the violation of any of the provisions of Ark. Code Ann. § 4-28-401

or as a result of any activities

et seq.,

conducted in the State of Arkansas giving rise to a cause of action.

It is hereby agreed that consent for service is irrevocable, and service on the Attorney General of the State of

Arkansas shall be binding on this organization as if due service had been made on its agents in person.

_____________________

__________________________________________

Date Signed

Legal Name of Fund-Raising Counsel

BY:

___________________________________________

Signature

___________________________________________

Printed Name

___________________________________________

Title/Official Position

NOTARY

STATE OF_______________

)

) SS.

COUNTY OF _____________

)

Subscribed and sworn to, before me, a Notary Public in, and for, said County and State, this _______ day of

________________, 20____.

My Commission Expires:

_______________________________________________________

______/______/_____

Signature of Notary Public

_______________________________________________________

County of Residence

Printed Name

__________________

STAMP or SEAL:

Fund-Raising Counsel Application For Registration Form - Office Of The Attorney General Page 5