Appointment Of Statutory Agent For Service Unincorporated Association

SECRETARY OF THE STATE OF CONNECTICUT MAILING ADDRESS: COMMERCIAL RECORDING DIVISION, CONNECTICUT SECRETARY OF THE STATE, P.O. BOX 150470, HARTFORD, CT 06115-0470 DELIVERY ADDRESS: COMMERCIAL RECORDING DIVISION, CONNECTICUT SECRETARY OF THE STATE, 30 TRINITY STREET, HARTFORD, CT 06106 PHONE: 860-509-6003 WEBSITE: www.concord-sots.ct.gov APPOINTMENT OF STATUTORY AGENT FOR SERVICE UNINCORPORATED ASSOCIATION USE INK. COMPLETE ALL SECTIONS. PRINT OR TYPE. ATTACH 81/2 X 11 SHEETS IF NECESSARY. FILING PARTY (CONFIRMATION WILL BE SENT TO THIS ADDRESS): FILING FEE: $90 MAKE CHECKS PAYABLE TO "SECRETARY OF THE STATE" NAME: ADDRESS: CITY: STATE: ZIP: 1. NAME OF UNINCORPORATED ASSOCIATION: 2. ADDRESS OF PRINCIPAL OFFICE IN CONNECTICUT: ADDRESS: CITY: STATE: ZIP: THE ABOVE ASSOCIATION APPOINTS AS ITS STATUTORY AGENT FOR SERVICE ONE OF THE FOLLOWING: (A). NAME OF NATURAL PERSON WHO IS RESIDENT OF CONNECTICUT: BUSINESS ADDRESS: ADDRESS: RESIDENCE ADDRESS: ADDRESS: CITY: STATE: ZIP: CITY: STATE: ZIP: (B). NAME OF CONNECTICUT CORPORATION ADDRESS OF PRINCIPAL OFFICE IN CONNECTICUT ADDRESS: CITY: STATE: ZIP: PAGE 1 OF 2 FORM CXM-1-1.0 Rev. 5/2011 (C). NAME OF CORPORATION NOT ORGANIZED UNDER CONNECTICUT LAWS* WHICH HAS A CERTIFICATE OF AUTHORITY TO TRANSACT BUSINESS OR CONDUCT AFFAIRS IN THIS STATE.: ADDRESS OF PRINCIPAL OFFICE IN CONNECTICUT ADDRESS: CITY: STATE: ZIP: 3. ACCEPTANCE: NAME OF STATUTORY AGENT FOR SERVICE SIGNATURE STATUTORY AGENT FOR SERVICE 4. AUTHORIZATION: NAME OF PRESIDENT, VICE-PRESIDENT OR SECRETARY SIGNED (PRESIDENT, OR VICE-PRESIDENT, OR SECRETARY) INSTRUCTIONS DO NOT SCAN THIS PAGE FORM CXM-1-1.0 Rev. 5/2011