PAUL
D. PATE
Secretary of
St
a
t
e
State of
I
owa
APPLICATION
FO
R
CERTIFICATE OF AU
T
H
O
R
ITY
(N
O
N
P
R
OFIT
)
TO
THE SECRETARY
OF STATE OF
THE
STATE OF
IOWA:
Pursuant
to
the Revised Iowa Nonprofit Corporation
Act,
the undersigned corporation applies
for
a certificate of
authority to transact business in Iowa, and states:
1
.
The name
of
the corpora
t
ion is:
1A. [See Note 6] The name the corporation will use in Iowa, if different than the legal name of the corporation is:
2
.
The corporation is incorporated under the laws
of
the
state
[or
foreign country] o
f
:
3
.
The date
of
incorporation
of
t
he corpora
t
ion was:
4
.
The duration
of
the corpora
t
ion is:
5. The street address of its principal office is:
Address
City,
State,
Z
ip
6. The street address of its registered office in Iowa and the name of its registered agent at that office
Name
A
ddress
City,
State,
Z
ip
7. Check one: The corporation has members. The corporation has no members.
8. The names and usual business or home addresses of its current directors and officers:
Name
A
ddress
City,
State,
Z
ip
Name
A
ddress
City,
State,
Z
ip
635_0106
1/15
Name
A
ddress
Ci
t
y
,
St
a
t
e
,
Z
ip
Name
A
ddress
Ci
t
y
,
St
a
t
e
,
Z
ip
[Please attach additional pages as necessary]
9.
A certificate of existence, or a document of similar import, duly authenticated within 90
days prior to the date of this application, by the secretary of state or other official having
custody of corporate records in the state or country of incorporation, accompanies this
application.
10
.
S
igna
t
ure
T
ype or prin
t
name and
t
i
t
le
NOTES:
1. The filing fee is $25.00. Make checks payable to SECRETARY OF STATE.
2. A certificate of existence, or a document of similar import, duly authenticated within 90 days prior to the date
of this application, by the secretary of state or other official having custody of corporate records in the state or
country of incorporation, must accompany this application.
3. The document is to be signed by the chairperson of the board, the president, or other officer of the corpora
t
ion
.
If directors have not been selected, the document is to be signed by an incorporator. If the corporation is in the
hands of a court appointed fiduciary, the document is to be signed by the fiduciary. A copy of a signature is
acceptable for filing. Verification is not required.
4. One copy of the document is to be delivered to the Secretary of State for filing.
5. The effective time and date of the document is the later of the following:
a. the time of filing on the date it is filed;
b. the time specified in the document on the date it is filed;
c. the time and date specified in the document, not later than 90 days after the date it is filed.
6. If the name of the corporation does not satisfy the requirements of section 1506 of the Revised Iowa Nonprofit
Corporation Act,
t
he
corporation may use a f
ic
t
i
t
ious name
t
o
t
ransac
t
business in
I
owa i
f
t
he
corporation's real
name
is unavailable and the corporation delivers to the secretary of state for filing a copy of the resolution of its board of
directors, certified by its secretary, adopting the fictitious name.
7. The information you provide will be open to public inspection under Iowa Code chapter 22.11.
SECRETARY OF STATE
B
u
s
in
ess
Ser
v
ices Division
Lucas B
uilding,
1st Floor
Des Moines, IA 50319
P
hone
:
(515) 281-5204
Fax:
(515) 242-5953
Website: s os.iowa.gov