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FORM NFP 113.15(rev. Dec. 2003)
APPLICATION FOR 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
217-782-1834
www.cyberdriveillinois.com
Remit payment in the form of a cashier’s 
check, certified check, money order or an 
Illinois attorney’s or CPA’s check payable 
to Secretary of State.
___________________________________ File #______________________________    Filing Fee: $50              Approved: ___________
———— Submit in duplicate ———— Type or Print clearly in black ink ———— Do not write above this line ———— 
1. a. Corporate Name: _____________________________________________________________________________

b. 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. Date of Incorporation:__________________________________________________________________________
c. Period of Duration:_____________________________________________________________________________
3. a. Address of Principal Office, wherever located:_______________________________________________________
    ____________________________________________________________________________________________
b. Address of Principal Office in Illinois:______________________________________________________________
    ____________________________________________________________________________________________
4.   Name and Address of Registered Agent and Registered Office in Illinois:

      Registered Agent:_______________________________________________________________________________
                                                             First Name                                            Middle Name                                                  Last Name

      Registered Office:_______________________________________________________________________________
                                                                Number                                                     Street                                Suite # (P.O. Box alone is unacceptable)

      Registered Office_______________________________________________________________________________
                                                                   City                                                     ZIP Code                                                        County

5. States and Countries in which Corporation is admitted or qualified to conduct affairs:__________________________

6. Names and respective addresses of Corporation’s officers and directors:
                                                                                  Street Address                                      City                               State       ZIP

President
Secretary
Director
Director
Director
                  If there are additional officers or more than three directors, please attach list.

                               Printed by authority of the State of Illinois. January 2015 - 1 - C 160.15

7. Purpose(s) for which the Corporation is organized and proposes to pursue in the conduct of affairs in this State:
                               For more space, attach additional sheets of this size.

8. This application must be accompanied by an originally certified copy of the Articles of Incorporation and any amend-
ments or mergers, duly authenticated within the last 90 days by the proper officer of the state or country wherein the
corporation is incorporated.

9. 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)

A Corporation that is to function as a club, as defined in Section 1-3.24 of the Liquor Control Act of 1934, must insert in its
purpose clause a statement that it will comply with the State and local laws and ordinances relating to alcoholic
liquors.