Application For Amended Certificate Of Authority (Nonprofit) {SS-4434}

For Office Use Only Corporate Filings 312 Rosa L. Parks Ave. 6th Floor, William R. Snodgrass Tower Nashville, TN 37243 APPLICATION FOR AMENDED CERTIFICATE OF AUTHORITY (NONPROFIT) Pursuant to the provisions of Section 48-65-104 of the Tennessee Nonprofit CorporationAct, the undersigned corporation herebyapplies for an amended certificate of authority to transact business or conduct affairs in the State of Tennessee, and for that purpose sets forth: 1. The name of the corporation is If different, the name under which the certificate of authority is to be obtained is 2. The state or country under whose law it is incorporated is 3. The date of its incorporation is other than perpetual, is (must be month, day , and year), and the period of duration, if 4. The complete street address (including zip code) of its principal office is Street City State/Country Zip Code 5. The complete street address (including the county and the zip code) of its registered office in Tennessee is Street City State/Country Zip Code Registered agent 6. The names and complete business addresses (including zip code) of its current officers are: (Attach separate sheet if necessary.) 7. The names and complete business addresses (including zip code) of its current board of directors are: (Attach separate sheet if necessary.) 8. The corporation has members. The corporation has no members. NOTE: Please mark the applicable box in #8. [ ] a public benefit corporation, or a mutual benefit 9. The corporation is a nonprofit corporation. 10. If the corporation had been incorporated in Tennessee, it would be corporation. [NOTE: Please mark the applicable box in #10.] 11. If the document is not to be effective upon filing by the Secretary of State, the delayed effective date/time is , (date) (time). [NOTE: A delayed effective date shall not be later than the 90th day after the date this document is filed by the Secretary of State.] [NOTE: This application must be accompanied by a certificate of existence or a document of similar import (for example, a certificategood standing) of duly authenticated by the Secretary of State or other official having custody of corporate records in the state or country unde r whose law it is incorporated. The certificate shall not bear a date of more than two (2) months prior to the date the application is successful ly filed in Tennessee.] Signature Date Name of Corporation Signer's Capacity Signature SS-4434 (Rev. 7/00) Name (typed or printed) RDA 1678 American LegalNet, Inc. www.FormsWorkFlow.com