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This is a North Carolina form that can be used for Nonprofit Corporation within Secretary Of State.
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STATE OF NORTH CAROLINA Department of the Secretary of State STATEMENT OF APPOINTMENT OF AGENT FOR A NONPROFIT ASSOCIATION Pursuant to §59B-11 of the General Statutes of North Carolina, the undersigned Nonprofit Association submits the following for the purpose of designating an agent and the agent's address in the State of North Carolina. 1. 2. The name of the Nonprofit Association is: _____________________________________________________________ The street address and county of the Nonprofit Association is: Number and Street: _______________________________________________________________________ City, State, Zip Code: ________________________________________ 3. County: _________________ The mailing address if different from the street address of the Nonprofit Association: __________________________________________________________________________________________ The street address in North Carolina of the Nonprofit Association's Agent for service of process is: Number and Street: ________________________________________________________________________ City, State, Zip Code: ________________________________________ County: _____________________ 4. 5. The mailing address if different from the street address of the Nonprofit Association's Agent for service of process is: ______________________________________________________________________________________________ 6. The name of the designated registered agent and the designated registered agent's written consent to the appointment appears below: ________________________________________________ (Type or Print Name of New Agent) ________________________________________ (Signature & Title*) 7. This statement will be effective upon filing, unless a date and/or time is specified: _____________________ 8. This is the _____day of _______________, 20____. __________________________________________ (Name of Entity) __________________________________________ (Signature) __________________________________________ (Type or Print Name and Title) Notes: 1. Filing fee is $5.00. One executed statement must be filed with the Secretary of State. (January 2007) CORPORATIONS DIVISION P.O. BOX 29622 (Form NA-01) RALEIGH, NC 27626-0622 American LegalNet, Inc. www.FormsWorkFlow.com