Nonstock Application For Amended Certificate Of Authority Form Page 2
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2The application must be signed, in the presence of a notary public, by the chairman of the board of directors, or by the president or by
another officer.
I DECLARE AND AFFIRM UNDER THE PENALTY OF PERJURY THAT THIS APPLICATION IS IN ALL THINGS, TRUE
AND CORRECT.
Dated _________________
__________________________________________________
(Signature)
__________________________________________________
STATE OF ___________________________
(Title)
__________________________
COUNTY OF
I, ________________________________________, a notary public, do hereby certify that on this _______ day of ________________________,
personally appeared before me ________________________________________________ who, being by me first duly sworn, declared that he/she
is the ____________________________ of _____________________________________________, that he/she signed the foregoing document as
officer of the corporation, and the statements therein contained are true.
_______________________________
__________________________________________________
My Commission Expires
(Notary Public)
Notarial Seal
FILING FEE: $20
FILING INSTRUCTIONS:
A foreign corporation authorized to do or engage in business in this state shall procure an amended certificate of authority in the event
it changes its corporate name or desires to pursue in this state other or additional purposes than those set forth in its prior application.
One ORIGINAL and One COPY of the application must be submitted.
The application must be accompanied by an original one page CERTIFICATE OF FACT or NAME CHANGE showing both the
former name and the change to the new name. The certificate must be obtained from the Secretary of State in the state under whose
laws it is incorporated.
nonprofitnonstockamendmentauthority July 2005
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