Application For Certificate Of Authority Of A Cooperative Association {CAF-1}

FILE ONE ORIGINAL (Two if you want a filed stamped copy returned to you.)FILING FEE: $100 (profit) $50 (non-profit) *Fee Waived for Veteran-owned corporationControl # 1.Home State Information: a.Principal office address of thecorporation is: No. & Street: City: State: Zip Code: b.Mailing address, if different fromabove address:b.Designated (physical) officeaddress in West Virginia, if any: Zip Code: State: City: Zip Code: State: City: c.Located in the County of: CHECK HERE to indicate you have obtained and submitted with this application a CERTIFICATE OF EXISTENCE (GOOD STANDING), dated during the current tax year, from your home state of original incorporation as required to process your application. The certificate may be obtained by contacting the Secretary of State's Office in the home state of original incorporation. Street/PO Box:2.Principal Office Information:a.The name of the Agricultural CooperativeAssociation as it is registered in its homestate is:3.West Virginia Office Information: b.State of Date of Incorporation: Duration (no. yrs. or perpetual) a.Corporate name to be used in WV:[See Section 1. of the attached instructions pertaining to name requirements. This name is your official name and must be used in its entirety when in use unless a Trade Name (DBA) is registered with the Office of Secretary of State, according to Chapter 47-8 of the West Virginia Code. To register a Trade Name (DBA) you must complete a Trade Name Registration (Form NR-3).] No. & Street:Home state name as listed on line 1a. above, if available. (If name is notavailable, check DBA Name box below and follow special instructions under Section 3a. attached to this application.) Forced DBA* Name:*See special instructions in Section 3a. regarding the Letter of Resolution approvinguse of a "forced DBA Name" attached to this application. View a sample Letter of Resolution . The undersigned, having authority to transact business on behalf of a foreign (out-of-state) registered Agricultural Cooperative Association, agrees to comply with the requirements of West Virginia Code 24719-4 to apply for Certificate of Authority. Zip Code: State: City: Street/PO Box: d.Mailing address in West Virginia,if different from above: County:West Virginia Secretary of State Business & Licensing Division Tel: (304)558-8000 Fax: (304)558-8381 Website: www.wvsos.gov APPLICATION FOR CERTIFICATE OF AUTHORITY OF AN AGRICULTURAL COOPERATIVE ASSOCIATION Form CAF-1 Rev. 6/2018 b.Will the incorporation elect to be organized for purposes as a 223Benefit Corporation224 per West Virginia Code 24731F ? ONLYapplicable to "FOR PROFIT" corporations; "NON-PROFIT" corporations CANNOT elect this status.Page 26.Website address of the business, if any (ex: yourdomainname.com): 5.E-mail address where business correspondence may be received:APPLICATION FOR CERTIFICATE OF AUTHORITY OF AN AGRICULTURAL COOPERATIVE ASSOCIATION Zip Code: State: City: No. & Street: 4.Agent for Service of Process:Properly designated person or companyto whom notice of legal process may besent, if any. Name: b.Located in how many West Virginia counties? If "Yes"... a. How many businesses? Yes No Decline to answer* Answer a. and b. below. 7.Do you own or operate more than one business in West Virginia? 8. a. Proposed purpose for transaction of business in West Virginia is (attach additional pages if necessary): (Describe the type[s] of business activity which will be conducted, for example, 223agricultural production of grain and poultry.224 Per 24719-4-3 of the WV Code, the association may be organized to "engage in one or more qualified activities in connection with the marketing or selling of agricultural products or the goods and services of its members or those purchased from other persons; or in connection with the manufacturing, selling or supplying to its members of machinery, equipment or supplies; or in securing and disseminating market information; or in the financing directly, through agricultural credit associations, and/or otherwise, the above- enumerated activities; or in any one or more of the activities specified herein." "Agricultural products" are defined as 223horticultural, viticultural, forestry, dairy, livestock, poultry, bee and any farm products, in their natural form or process." "Goods and services" means food and beverages, arts and crafts, woodworking and furniture-making, and recycling, composting and repurposing materials.) No [Proceed to Section 9.] Yes Officer Title Officer Name No. & Street Address City State Zip Code b.Officers and Directors: (At least three (3) Directors must be listed; add additional pages if necessary) For Profit Non-Profit a.Corporation is organized as (check one):10.Corporate Status Information: Yes No [Proceed to Section 10.][If "Yes," you must complete the Scrap Metal Dealer Registration Form (Form SMD-1 ) and proceed to Section 10.]9.Is the business a Scrap Metal Dealer? [If "Yes," the corporation must be formed FOR PROFIT and the purpose(s) indicated in Section 10a. above must include a "general public benefit" as set forth in 24731F-3-301(a) of the West Virginia Code. Per 24731F-1-102(c) , 223general public benefit224 means 223a material positive impact on society and the environment taken as a whole, as measured by a third-party standard, from the business and operations of a benefit corporation."]. Page 3 *Important Legal Notice Regarding Signature: Per West Virginia Code 24731D-1-129. Penalty for signing false document. Any personwho signs a document he or she knows is false in any material respect and knows that the document is to be delivered to the secretary of state for filing is guilty of a misdemeanor and, upon conviction thereof, shall be fined not more than one thousand dollars or confined in the county or regional jail not more than one year, or both. Important Note: This form is a public document. Please do NOT provide any personal identifiable information on this form such as social security number, bank account numbers, credit card numbers, tax identification or driver's license numbers. Date: c.Signature: b.Print or type name of signer: a.Contact person to reach in case there is a problem with filing: 13.Contact and Signature Information* (See below Important Legal Notice Regarding Signature): 12.The number of acres of land it holds or expects to hold in West Virginia is: Phone: Title/Capacity of signer:APPLICATION FOR CERTIFICATE OF AUTHORITY OF AN AGRICULTURAL COOPERATIVE ASSOCIATIONPer WV Code 59-1-2(j) effective July 1, 2015, the registration fee is waived for entities that meet the requirements as a "veteran-owned" organization. See attached instructions to determine if the organization qualifies for this waiver. In addition, a "veteran-owned" entity will have four (4) consecutive years of Annual Report fees waived AFTER the organization's initial formation [see WV Code 59-1-2a(m) ].11.Is the organization a "veteran-owned" organization?National Personnel Records Center Military Personnel Records 1 Archives Drive St. Louis, MO 63138 Toll free: 1-86-NARA-NARA or 1-866-272-6272 Phone: 314-801-0800 www.archives.gov/veterans/military-service-recordsYou may obtain a copy of your Veterans Affairs Form DD214 by contacting: Yes (If "Yes," attach Form DD214) No CHECK BOX indicating you have attached Veteran Affairs Form DD214 Effective JULY 1, 2015, to meet the requirements for a 223veteran-owned224 organization, the entity filing the registration must meet the following criteria per West Virginia Code 24759-1-2a : 1.A 223veteran224 must be honorably discharged or under honorable conditions, and2.A 223veteran-owned business224 means a business that meets one of the following criteria:oIs at least fifty-one percent (51%) unconditionally owned by one or more veterans; oroIn the case of a publicly owned business, at least fifty-one percent (51%) of the stock is unconditionally owned by one ormore veterans. CHECK THE BOX to indicate you have obtained and submitted with this application a CERTIFICATE OF EXISTENCE (GOOD STANDING), dated during the current tax year, from your home state of original organization as required to process your application. The certif