State Form 39034 - Application For Amended Certificate Of Authority
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1APPLICATION FOR AMENDED
SUE ANNE GILROY
SECRETARY OF STATE
CERTIFICATE OF AUTHORITY
CORPORATIONS DIVISION
302 W. Washington St., Rm. E018
State Form 39034 (R5 / 4-95) Corporate Form No. 115
Indianapolis, IN 46204
Telephone: (317) 232-6576
Approved by the State Board of Accounts 1995
Use 8 1/2" x 11" white paper for inserts.
INSTRUCTIONS:
Indiana Code 23-1-49-4; 23-17-26-4
Present original and two (2) copies to address in upper right corner of this form.
FILING FEE: $30.00
Please TYPE or PRINT.
NOTE:
This application must be accompanied by a certificate of existence duly authenticated by the proper authority from the corporation's
domicile state.
APPLICATION FOR
AMENDED CERTIFICATE OF AUTHORITY
OF
Name of Corporation
A FOREIGN CORPORATION ADMITTED TO
TRANSACT BUSINESS IN INDIANA
The undersigned officers of ___________________________________________________________________________________
(hereinafter referred to as the "Corporation"), which exists pursuant to the provisions of the laws of __________________________
as amended, desire to obtain an Amended Certificate of Authority.
ARTICLE II - REPRESENTATION BY THE WITHDRAWING CORPORATION
1. The above Corporation received a Certificate of Authority to transact business in the State of Indiana on the ______________
day of ___________________________________________ , 19 _________ .
2. The Corporation desires to change its corporate name in Indiana as follows.
3. The Corporation has changed the period of its duration from _________________________________________________
to ___________________________________________________.
4. The Corporation has changed the state or country of its incorporation from ______________________________________
to ______________________________________.
In Witness Whereof, the undersigned, being the ________________________________________________________ of said
Title
Corporation executes this Application for Amended Certificate of Authority and verifies, subject to penalties of perjury, that the
statements contained herein are true, this ____________ day of ____________________________________ , 19 ________.
Signature
Printed name
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