Form Mnpca-5 - Statement Of Intention To Carry On Activities Under An Assumed Or Fictitious Name For A Nonprofit Corporation - 2004 Page 2

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FOURTH:
(Foreign Corporation Only)
Jurisdiction of incorporation ______________________________________________________ and the date on which
the corporation was authorized to carry on activities in Maine _____________________________________________
DATED _________________________
*By __________________________________________________
(signature)
__________________________________________________
(type or print name and capacity)
*By __________________________________________________
(signature)
__________________________________________________
(type or print name and capacity)
*If this is a domestic corporation, this document MUST be signed by:
(13-B MRSA
§104.1.B)
(1) the Clerk or Secretary OR
(2) the President or a Vice-President together with the Secretary or an assistant. secretary, or a 2nd certifying officer OR
(3) if no such officers, then a majority of the Directors OR
(4) if no such directors, then the Members.
*If this is a foreign corporation, this document MUST be signed by any duly authorized individual.
(13-B MRSA
§104.1.D)
Please remit your payment made payable to the Maine Secretary of State.
SUBMIT COMPLETED FORMS TO: CORPORATE EXAMINING SECTION, SECRETARY OF STATE,
101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101
FORM NO. MNPCA-5 (2 of 2) Rev. 8/1/2004
TEL. (207) 624-7740

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