State of North Carolina Department of the Secretary of State APPLICATION FOR AMENDED CERTIFICATE OF AUTHORITY NONPROFIT CORPORATION Pursuant to 55A-15-04 of the General Statutes of North Carolina, the undersigned corporation herebyapplies for an Amended Certificate of Authority to conduct affairs in the State of North Carolina and forthat purpose submits the following statement. 1. The name of the corporation is:_______________________________________________________ 2. The name the corporation is currently using in the State of North Carolina is: ____________________________________________________________________________________ 3. The state or country of organization is:_________________________________________________ 4. The date the corporation was authorized to conduct affairs in the State of North Carolina is: ____________________________________________________________________________________ 5. This application is filed for the following reason (complete all applicable items): a. The corporation has changed its corporate name to:* _________________________________________________________________________________ b. The name the corporation will hereafter use in the State of North Carolina is changed to: _________________________________________________________________________________ c. The corporation has changed its period of duration to:_______________________________ d. The corporation has changed the state or country of its incorporation to:_________________6. Attached is a certificate attesting to the change, duly authenticated by the Secretary of State or other official having custody of corporate records in the state or country of incorporation. 7. If the corporation is required to use a fictitious name in order to conduct affairs in this State, a copy of the resolution of its board of directors, certified by its secretary, adopting the fictitious name is attached. 8. This application will be effective upon filing, unless a date and/or time is specified:_______________This the_____day of _____________________, 20_____ ____________________________________ Name of Corporation ____________________________________ Signature ____________________________________ Type or Print Name and TitleNOTES 1. Filing fee is $25. One executed original and one exact or conformed copy of this application must be filed with the Secretary of State. *If the name of the corporation as changed is unavailable for use in North Carolina, indicate this fact and state the name the corporationwishes to use in North Carolina on 5b. (See N.C.G.S. 55A-15-06) (Revised January 2000) (Form N-10)CORPORATIONS DIVISION P.O. BOX 29622 RALEIGH, NC 27626-0622<<<<<<<<<********>>>>>>>>>>>>> 2 APPLICATION FOR AMENDED CERTIFICATE OF AUTHORITY NONPROFIT CORPORATIONItem 1 Enter the complete name of the corporation exactly as it appears on the Certificate of Authority. Item 2 Enter the corporation name used in North Carolina exactly as it appears on the Certificate of Authority. Item 3 Enter the state or country of incorporation.Item 4 Enter the date the corporation was authorized to conduct affairs in North Carolina.Item 5 Complete the applicable items.Item 6 See form Item 7 See form Item 8 The document will be effective on the date and at the time of filing, unless a delayed date or an effective time (on the day of filing) is specified. If a delayed effective date is specified without a time, the document will be effective at 11:59:59 p.m. on the day specified. If a delayed effective date is specified with a time, the document will be effective on the day and at the time specified. A delayed effective date may be specified th up to and including the 90 day after the day of filing.Date and Execution Enter the date the document was executed. In the blanks provided enter: The name of the corporation as it appears in item 1. The signature of the representative of the corporation executing the document (may be the presiding officer of the board of directors or any officer of the corporation). The name and title of the representative.