Form Cony - Certificate Of Conversion - Maine Secretary Of State - 2000 Page 2
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1
2(MUST BE COMPLETED BY THE CONVERTING BUSINESS ENTITY)
Name and Type of Participating Business Entity
Dated
Authorized Signature
Type or Print Name and Capacity
Authorized Signature
Type or Print
Name
and Capacity
(MUST BE COMPLETED BY THE CONVERTING BUSINESS ENTITY, IF A CORPORATION)
The address of the registered office, including the street, city, state and zip code, in the State of Maine is as follows'
(MUST BE COMPLETED BY THE CONVERTING BUSINESS ENTITY, IF A DOMESTIC CORPORATION)
The undersigned clerk, secretary or assistant secretary certifies that he/she has custody of the minutes showing the above action by the
shareholders.
Authorized Signature
Type or Print Name and Capacity
MUST
BE COMPLETED
BY THE
RESULTING
BUSINESS
ENTITY
THE UNDERSIGNED
HEREBY
ACCEPrS
THE APPOINTMENT
AS CLERK/REGISTERED
AGENT
FOR
THE RESULTING
BUSINESS ENTITY
.
CLERK/REGISTERED
AGENT
DATED
(tyPe or print name)
(signattlre)
For Registered Agent which is a Corporation
Name of Corporation
By
(audlorized signature)
(tyPe or print name and capacity)
SUBMIT COMPLETED FORMS TO: CORPORATE EXAMINING SECTION, SECRETARYOF STATE,
101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101
FORM NO. CONY 2000
TEL. (201) 287-4195
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