STATE OF SOUTH CAROLINA 
                                         SECRETARY OF STATE 

APPLICATION FOR AN AMENDED CERTIFICATE OF AUTHORITY BY A FOREIGN CORPORATION TO 
                        TRANSACT BUSINESS IN THE STATE OF SOUTH CAROLINA 

Pursuant to Section 33-15-104 of the 1976 South Carolina Code of Laws, as amended, the undersigned corporation 
hereby applies for an amended certificate of authority to transact business in the State of South Carolina and for that 
purpose submits the following statement: 

1. The name of the corporation is:

1A. The above named corporation received a Certificate of Authority to transact business in South Carolina on 
______________. 

2. This application is filed for the following reason (complete all applicable items):

a. The corporation has changed its corporate name as follows:

b. The corporation has changed its duration to _______________.

c. The corporation has changed the state or country of its incorporation to ___________________________

d. The corporation has converted to _______________________ 

3. The name of the corporation for the purpose of transacting business in South Carolina is (See Sections 33-4-101 and
33-15-106) and see Section 33-19-500(b)(1) if the corporation is a professional corporation

4. It is incorporated as (check applicable item)      a general business corporation,  a professional corporation under 
the laws of the state of ______________________________________________

5. The date of its incorporation is ______________ and the period of its duration is _______________

6. The address of the principal office of the corporation in the jurisdiction of its incorporation is:

_____________________________________________________________________________________________ 
(Street Address) 

_____________________________________________________________________________________________ 
(City, State, Zip Code) 

                                            Form Revised by South Carolina Secretary of State, June 2019 
                                                                                                              F0004 

                                                                                                 Name of Corporation 
7.  The address of the registered office in the state of South Carolina is: 
    
   _____________________________________________________________________________________________ 
   (Street Address) 
    
   ______________________________________________________ South Carolina           _____________________ 
   (City)                                                                     (Zip Code) 
 
8.  The name of the registered agent in this state at such address is 
    
   _____________________________________________________________________________________________ 
   (Name) 
    
9. The name and usual business address of the corporation’s directors (if the corporation has no directors, then the 
   name and address of the persons who are exercising the statutory authority of the directors on behalf of the 
   corporation) and principal officers: 
a) 
   _____________________________________________________________________________________________ 
   (Director Name) 
    
   _____________________________________________________________________________________________ 
   (Business Address) 
    
   _____________________________________________________________________________________________ 
   (City, State, Zip Code) 
                        
   _____________________________________________________________________________________________ 
   (Director Name) 
    
   _____________________________________________________________________________________________ 
   (Business Address) 
    
   _____________________________________________________________________________________________ 
   (City, State, Zip Code) 
    
   _____________________________________________________________________________________________ 
   (Director Name) 
    
   _____________________________________________________________________________________________ 
   (Business Address) 
    
   _____________________________________________________________________________________________ 
   (City, State, Zip Code) 
     
b) 
   _____________________________________________________________________________________________ 
   (Principal Officer Name) 
    
   _____________________________________________________________________________________________ 
   (Principal Officer Position) 
    
   _____________________________________________________________________________________________ 
   (Address) 
    
                                             Form Revised by South Carolina Secretary of State, June 2019 
                                                                                                                F0004 

                                                                                      Name of Corporation 
  
 _____________________________________________________________________________________________ 
 (City, State, Zip Code) 
    
 _____________________________________________________________________________________________ 
 (Principal Officer Name) 
  
 _____________________________________________________________________________________________ 
 (Principal Officer Position) 
  
 _____________________________________________________________________________________________ 
 (Address) 
  
 _____________________________________________________________________________________________ 
 (City, State, Zip Code) 
 
 _____________________________________________________________________________________________ 
 (Principal Officer Name) 
  
 _____________________________________________________________________________________________ 
 (Principal Officer Position) 
  
 _____________________________________________________________________________________________ 
 (Address) 
  
 _____________________________________________________________________________________________ 
 (City, State, Zip Code) 
  
10.  The aggregate number of shares which the corporation has authority to issue, itemized by classes and series, if any, 
  within a class:  
 
   Class of Shares (and Series, if any)  Authorized Number of Each Class (and Series) 
   ________________________________      ______________ 
   ________________________________      ______________ 
   ________________________________      ______________ 
11.  Unless a delated date is specified, this application shall be effective when accepted for filing by the Secretary of 
  State (See Section 33-1-230): ___________________ 
   
Date: ___________________ 
 
Name of Corporation: 
 
____________________________________________________________________________________________ 
Signature of Officer 
 
____________________________________________________________________________________________ 
Type or Print Name 
 
____________________________________________________________________________________________ 
Position of Officer 

                                            Form Revised by South Carolina Secretary of State, June 2019 
                                                                                                 F0004 

                                         FILING INSTRUCTIONS 
                                                
 1. Two copies of this application, the original and either a duplicate original or a conformed copy, must 
    by filed. 
 
 2. If the space in this form is insufficient, please attach additional sheets containing a reference to the 
    appropriate paragraph in this form. 
 
 3. Schedule of Fees (payable at the time of filing this document) 
 
    Fee for filing Application                                       $10.00 
    Filing Tax                                                       $100.00 
    Total (payable to the Secretary of State)                        $110.00 
 
 4. An original certificate of existence (or a record of similar import) no more than 30 days old from the
       original state or jurisdiction where the corporation is incorporated must accompany the application if the
       entity is changing its name or domestic state / jurisdiction. 
 
 5. If the applicant corporation’s domestic name is unavailable in South Carolina, then it must file a 
    certified copy of the board of director’s resolution approving the fictitious name along with this 
    application pursuant to Section 33-15-106(a)(2). (additional $10 filing fee) 
 
    Return to:  Secretary of State 
              1205 Pendleton Street, Suite 525 
              Columbia, SC 29201 
 
                                                  Form Revised by South Carolina Secretary of State, June 2019 
                                                                                                       F0004