BUSINESS REGISTRATION DIVISION P. O. BOX 29622 RALEIGH, NC 27626-0622
(Revised July 2017)
Instructions for Filing
APPLICATION FOR CERTIFICATE OF AUTHORITY
Item 1 Enter the complete name of the corporation exactly as it appears in the records of the appropriate
official in the state or country of incorporation. If the name cannot be used in North Carolina,
enter the name (including a corporate ending) that it wishes to use in North Carolina.
Item 2 Enter the state or country of incorporation.
Item 3 Enter the date of incorporation
Item 4 Check the applicable box for the period of duration and insert date if date certain.
Item 5 Select item “a” if the corporation has a principal office. Enter the complete street address of the
principal office and the county in which it is located. If mail is not delivered to the street address
of the principal office or if you prefer to receive mail at a P.O. Box or Drawer, enter the
complete mailing address of the principal office.
Select item “b” if the corporation does not have a principal office.
Item 6 Enter the complete street address of the corporation’s registered office and the county in which it
Item 7 Enter the complete mailing address of the corporation’s registered agent, only if mail is not
delivered to the street address above or if you prefer to receive mail at a P. O. Box or Drawer.
Item 8 Enter the name of the registered agent. The registered agent must be a North Carolina resident,
an existing domestic business corporation, nonprofit corporation or limited liability company, or
a foreign business corporation, nonprofit corporation or limited liability company authorized to
transact business or conduct affairs in North Carolina.
Item 9 Enter the names, titles, and usual business address of the current officers of the corporation.
Item 10 See Form
Item 11 See Form
Item 12 The document will be effective on the date and at the time of filing, unless a delayed date or an
effective time (on the date of filing) is specified. If a delayed effective date is specified without
a time, it will be effective at 11:59:59 p.m. A delayed effective date may be specified up to and
including the 90
day after the day of filing.
Date and Execution
Enter the date the document was executed.
In the blanks provided enter:
• The name of the corporation as it appears in Item 1
The signature of the representative of the corporation executing the document (may
be the chairman of the board of directors or any officer of the corporation).
The name and title of the above-signed representative.