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FORM   NFP 113.40     (rev. Dec. 2003)
APPLICATION FOR AMENDED
AUTHORITY TO CONDUCT AFFAIRS
IN ILLINOIS (Foreign Corporations) 
General Not For Profit Corporation Act
Secretary of State
Department   of Business Services
501 S. Second   St., Rm. 350 
Springfield, IL 62756
217-782-6961
www.ilsos.gov

Remit payment in the form of a 
check or money order payable 
to Secretary of State.

____________________________________ File #_____________________________    Filing Fee: $25                Approved: ___________
    ———— Submit in duplicate ———— Type or Print clearly in black ink ———— Do not write above this line ———— 

1. Corporate Name: ________________________________________________________________________________

 If a Change of Name is being Reported, the New Corporate Name: ________________________________________

 Assumed Corporate Name (Complete only if the new corporate name is not available in this state.):

 ______________________________________________________________________________________________
 By electing this assumed name, the Corporation hereby agrees NOT to use its corporate name in the transaction of
 business in Illinois. Form NFP 104.15 is attached.

2. a. State or Country of Incorporation: _________________________________________________________________

 b. If changed, Period of Duration: ___________________________________________________________________

3. If changed, Purpose(s) for which it is organized and proposes to pursue in the conduct of affairs in this State.
                      For more space, use reverse side or attach additional sheets of this size.

4. This application is accompanied by a copy of the Articles of Amendment to the Articles of Incorporation, if any, as evi-
 dence of any change of name, duration or purpose reported herein, such copy being duly authenticated by the proper
 officer of the State or Country wherein the corporation is incorporated, which certification is not more than 90 days old.

5. The undersigned Corporation has caused this statement to be signed by a duly authorized officer who affirms, under
 penalties of perjury, that the facts stated herein are true and correct. All signatures must be in        BLACK.INK

 Dated _______________________________ ,  _____    ________________________________________________
                         Month   Day                    Year                  Exact Name of Corporation

          ______________________________________
                      Any Authorized Officer’s Signature

          ______________________________________
                         Name and Title (type or print)

                                 Printed by authority of the State of Illinois. January 2015 — 1M — C 218.9