APPLICATION FOR

                  Secretary of State                          REGISTRATION OF

                                                              CORPORATE NAME
                  State of Iowa

    TO THE SECRETARY OF STATE OF THE STATE OF IOWA:

    The undersigned entity applies for the registration of its name, pursuant to the (check one)

             Iowa Business Corporation Act (profit corporation Iowa Code ch. 490).

             Revised Iowa Nonprofit Corporation Act (nonprofit corporation Iowa Code ch. 504).

    1.  The name of the business entity is ____________________________________________

    1A.  [If applicable]  The name to be registered if different than the name of the business entity because

        the real name is unavailable is _______________________________________________

    2.  The state or foreign country in which the business entity is incorporated/formed

        is _____________________________________________________________________

    3.  The date of incorporation/formation of the business entity is _________________________

    4.  A brief description of the nature of the business in which the entity is engaged is

        _______________________________________________________________________

    5.  A certificate of existence, or a document of similar import, from the state or country of
        incorporation/formation, accompanies this application.

    6.  The name and address of the applicant is:

        Name ________________________________________________________________

        Address    ______________________________________________________________

        City, State, Zip  __________________________________________________________

        Signature ______________________________________________________________

        Type or print name & title ___________________________________________________

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                                   INSTRUCTIONS

NOTES:

1. The filing fee is $2 .000 , and covers registration from the date the application is filed through 
   December 31 of the calendar year in which the application is filed. Make checks payable to 
   SECRETARY OF STATE.

2. The application is to be signed by the chairperson of the board of directors, the president, or 
   another officer of the corporation. It must also state the person's name and the capacity in 
   which the person is signed.

3. One copy of the document is to be delivered to the secretary of state for filing.

4. The name registration is effective through the end of the calendar year in which it is filed.

5. The information you provide will be open to public inspection under Iowa Code chapter 
   22.11.

                                   SECRETARY OF STATE
                                   Business Services Division
                                   Lucas Building, 1st Floor
                                   Des Moines, Iowa 50319

                                   Phone: (515) 281-5204
                                   FAX: (515) 242-5953     

                                    Website: sos.iowa.gov 

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