REGISTERED AGENT
STATEMENT OF APPOINTMENT
(Section 106.022, F.S.)
OFFICE USE ONLY
Original Appointment
Change of Appointment
Change of Mailing Address
Change of Physical Address
Registered Agent and Office Information
Name
Street Address
City
State
Mailing Address
City
State
I accept this appointment and confirm that I am familiar with and accept the obligations of the position as set
forth in Section 106.022, F.S. I also understand that I may resign this appointment by executing a written
statement of resignation and filing it with the applicable filing officer.
Signature of Registered Agent
Date
Former Registered Agent and Office Information (for changes only)
Name
Street Address
City
State
Committee or Organization Information
Name of Committee or Organization
Street Address
Telephone
City
State
Signature of Chairperson
Printed Name of Chairperson
Date
Form DS-DE 41 (revised 6/11)