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                   State of Missouri                                                                         Print          Reset
                   John R. Ashcroft, Secretary of State

                   Corporations Division
                   PO Box 778 / 600 W. Main St., Rm. 322
                   Jefferson City, MO 65102

                                           Application for Certificate of Authority
                                           of a Foreign Nonprofit Corporation
                                                        (Submit with filing fee of $25.00)

1. The Corporation’s name is

and it is organized and existing under the laws of

2. If the corporation’s name is unavailable, the name it will use in Missouri is

3. The date of its incorporation was                                     , and the period of its duration is 
                                           month/day/year

4. The address of its principal place of business is
                                                         Address                                             City/State/Zip 

5. The name and physical address of its registered agent and office in the State of Missouri is

            Name                                         Address                                             City/State/Zip 

6. The names of its officers and directors and their business or home addresses are as follows (attach additional sheets as necessary):

                   Name                                             Address                                  City/State/Zip 

    President 

    Vice President 

    Secretary 

    Treasurer 

    Director 

    Director 

7. The specific purpose(s) of its business in Missouri:

                                                        (Please see)next page

Name and address to return filed document:

Name:

Address:

City, State, and Zip Code:
                                                                                                             Corp. 55A (01/2017)

8. Does the corporation have members?  Yes               No 

9. If incorporated in Missouri would the corporation be a public benefit             or mutual benefit              Corporation?

10.   Check    box if you will be registered with the Department of Agriculture as a Family Farm or Authorized Farm Corporation as
          defined by section 350.010 RSMo.

11. The effective date of this document is the date it is filed by the Secretary of State of Missouri unless a future date is otherwise

indicated:
                                  Date may not be more than 90 days after the filing date in this Office

In Affirmation thereof, the facts stated above are true and correct:
(The undersigned understands that false statements made in this filing are subject to the penalties provided under Section 575.040, RSMo)

Authorized signature of officer or chairman of the board         Printed Name                           Title                Date

Note: You must submit a current (not more than 60 days old) certificate of good standing or certificate of existence with this application.
This may be obtained from the Secretary of State or other authority that issues corporate charters in your state of domicile.

                                                                                                                    Corp. 55A (01/2017)