Application For Reservation Of Name Under General Not For Profit Corporation Act Only {NFP-104.10}

FORM NFP 104.10 (rev. Aug. 2014) APPLICATION FOR RESERVATION OF NAME Under the General Not For Profit Corporation Act Secretary of State Department of Business Services 501 S. Second St., Rm. 350 Springfield, IL 62756 217-782-9520 217-782-6961 www.cyberdriveillinois.com Payment must be made by check or money order payable to Secretary of State. ($25 fee to each name reserved.) File # ___________________________ Approved: _________________ Pursuant to the provisions of "The General Not For Profit Corporation Act of 1986," the undersigned hereby submits the following Application for Reservation of Name. 1. The following name or names shall be reserved for a period of 90 days each: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 3. Name of applicant: __________________________________________________________________ ________________________________________________________________________________ (May contain the word "corporation", "incorporated", or "limited", or may contain an abbreviation of one such word) -------- Type or Print clearly in black ink -------- Do not write above this line -------- 2. A brief summary of the purpose intended to be conducted by the corporation is: 4. Address of applicant: ________________________________________________________________ Date: ________________________________ (Month Day) (Year) ________________________________________________________________________________ ____________________________________ ____________________________________ ______________________________________ ______________________________________ Signature of Applicant NOTE: If the applicant is an individual, it is to be signed by the applicant. If the applicant is a corporation, it is to be signed by the corporation's president or vice-president and verified by him/her and attested to by the secretary or an assistant secretary. Printed by authority of the State of Illinois. January 2015­ 1 ­ C 140.12 American LegalNet, Inc. www.FormsWorkFlow.com NOTICE OF TRANSFER OF RESERVED NAME Date Filing Fee $25 Approved to _______________________________________________________________________the right to use the in Illinois. This name was reserved on _________________________________________________________ The undersigned affirms, under penalties of perjury, that the facts stated herein are true. (Month Day) (Year) (Signature of Original Applicant) The undersigned_______________________________________________________hereby transfers (Name of Original Applicant) name _________________________________________________________________for corporate purposes Dated__________________________________ By: ____________________________________________ Attested by: _____________________________ ____________________________________________ (Type or Print Name) If a corporation, by its president or vice president * As the original applicant, I declare that this document has been examined by me and is to the best of my knowledge and belief, true, correct and complete. C-140.10 American LegalNet, Inc. www.FormsWorkFlow.com