| Contact Information |
| Address |
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| Suite, Apt. #, etc. |
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| City, State |
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| Zip |
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| Phone |
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| Fax |
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| Email Address |
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| Filing Information |
| Corporate Name |
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| (Name must include suffix such as "Corp", "Inc.",
"Incorporated", etc.) |
| Corporate Stock Shares (Cannot be zero) |
(ex. 100) |
| Principle Place of Business |
| Address |
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| Suite, Apt. #, etc. |
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| City, State |
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| Zip |
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| Business Mailing Address |
| If your corporate mailing address is the same as the
principle address above, please check the box below. Otherwise enter
your corporate mailing address. |
|
Mailing address same as principal address |
| Address |
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| Suite, Apt. #, etc. |
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| City, State |
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| Zip |
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| Name of Registered Agent (Check one) |
| For a fee
of $99.00 per year, Trust Business Systems will be your Registered
Agent. (Do not complete any of the boxes below.) |
|
Other (Complete information below) |
| Last Name |
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| First Name |
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| Middle Name |
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| Title (Sr. Jr. etc.) |
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| Email Address |
|
The Registered Agent must type their name in the "Registered Agent Signature' block below. RA signature MUST be an individual name. If the RA is a business entity, an individual must sign on the entity's behalf. Do not enter the name of the entity you are attempting to file as Registered Agent. A business entity cannot serve as its own RA.
Registered Agent Signature
This signature must be that of the individual "signing" this document electronically or be made with the full knowledge and permission of the individual, otherwise it constitutes forgery under s.831.06, Florida Statues. |
| Corporate Purpose |
Any and all lawful business
(Do not select if a "Professional Association".
You must list specific purpose below ) |
|
| Officer/Director Name and Address |
| Position Title (V, VP, etc.) |
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| Last Name |
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| First Name |
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| Middle Name |
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| Title (Sr. Jr. etc.) |
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| OR Entity Name to serve as Officer/Director |
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| Address |
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| Suite, Apt. #, etc. |
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| City, State |
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| Zip |
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| |
| Position Title (V, VP, etc.) |
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| Last Name |
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| First Name |
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| Middle Name |
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| Title (Sr. Jr. etc.) |
|
| OR Entity Name to serve as Officer/Director |
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| Address |
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| Suite, Apt. #, etc. |
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| City, State |
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| Zip |
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| |
| Position Title (V, VP, etc.) |
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| Last Name |
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| First Name |
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| Middle Name |
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| Title (Sr. Jr. etc.) |
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| OR Entity Name to serve as Officer/Director |
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| Address |
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| Suite, Apt. #, etc. |
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| City, State |
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| Zip |
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| |
| Position Title (V, VP, etc.) |
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| Last Name |
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| First Name |
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| Middle Name |
|
| Title (Sr. Jr. etc.) |
|
| OR Entity Name to serve as Officer/Director |
|
| Address |
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| Suite, Apt. #, etc. |
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| City, State |
|
| Zip |
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| |
| Position Title (V, VP, etc.) |
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| Last Name |
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| First Name |
|
| Middle Name |
|
| Title (Sr. Jr. etc.) |
|
| OR Entity Name to serve as Officer/Director |
|
| Address |
|
| Suite, Apt. #, etc. |
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| City, State |
|
| Zip |
|
| |
| Position Title (V, VP, etc.) |
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| Last Name |
|
| First Name |
|
| Middle Name |
|
| Title (Sr. Jr. etc.) |
|
| OR Entity Name to serve as Officer/Director |
|
| Address |
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| Suite, Apt. #, etc. |
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| City, State |
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| Zip |
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| Comments |
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