Application For Electronic Signature Verification Company

APPLICATION FORVERIFICATION COMPANYPursuant to the provisions of the Arkansas Electronic Records and Signatures Act of 1999, A.C.A. 25-31-101, theundersigned as the duly authorized and acting president, secretary, treasurer, superintendent or managingagent ofthe corporation named below for which this application is submitted, under oath, hereby states: 1.The name of the corporation is:The address of the corporation is:StreetCityStateZIP2.Fictitious name to be used in Arkansas:3.The state or foreign country under whose laws the corporation was incorporated is:4.Date incorporated:5.Period of Duration:6.Please state any other states in which you are currently acting as a verification company and how long you havebeen acting as a verification company in each state:7.Please deliver with the completed application a certificate of good-standing duly authorized by the Secretary ofState or other official having custody of corporate records in the state or country under whose laws the corpora-tion is incorporated.B.Please deliver with the completed application a copy of a surety bond in the amount of $250,000 made payableto the State of Arkansas.9.Any corporation incorporated in any other state than Arkansas making application to act as a verification companyin the State of Arkansas must obtain authority to do business in Arkansas prior to final approval of this application.Witness the hand and seal of the corporation executed under oath by the undersigned on thisday of , .I understand that knowingly signing a false document with the intent to file with the Arkansas Secretary of Stateis a Class C misdemeanor and is punishable by a fine up to $100.00 and/or imprisonment up to 30 days.Authorized SignatureTitle Rev. Authorizing Officer (Type or Print) 001027021n024030n030007r013027r031n027035025016007031n031r $'#$t 003n026020031025022037004020031031022r006025013021 American LegalNet, Inc. www.FormsWorkFlow.com