BUSINESS REGISTRATION DIVISION P. O. BOX 29622 RALEIGH, NC 27626-0622
(Revised August 2017) Form N-09
State of North Carolina
Department of the Secretary of State
APPLICATION FOR CERTIFICATE OF AUTHORITY
FOR NONPROFIT CORPORATION
Pursuant to §55A-15-03 of the General Statutes of North Carolina, the undersigned corporation hereby applies for a Certificate of
Authority to conduct affairs in the State of North Carolina, and for that purpose submits the following:
1. The name of the corporation is ______________________________________________________________________________
and if that name is unavailable for use in the State of North Carolina, the name the corporation wishes
to use is: _______________________________________________________________________________________________
2. The state or country under whose laws the corporation was organized is:_____________________________________________
3. The date of incorporation was ____________ ; its period of duration is:______________________________________________
4. The street address of the principal office of the corporation is:
Number and Street________________________________________________________________________________________
City, State, Zip Code______________________________________________________________________________________
5. The mailing address if different from the street address of the principal office of the corporation is:
_______________________________________________________________________________________________________
6. The street address and county of the registered office in the State of North Carolina is:
Number and Street________________________________________________________________________________________
City, State, Zip Code________________________________________________ County: _______________________________
7. The mailing address if different from the street address of the registered office in the State of North Carolina is:
_______________________________________________________________________________________________________
8. The name of the registered agent in the State of North Carolina is:__________________________________________________
9. The names and usual business addresses of the current officers of the corporation are:
Name Title Business Address
__________________________________ _________________ ____________________________________________
__________________________________ _________________ ____________________________________________
__________________________________ _________________ ____________________________________________
__________________________________ _________________ ____________________________________________
__________________________________ _________________ ____________________________________________
__________________________________ _________________ ____________________________________________
BUSINESS REGISTRATION DIVISION P. O. BOX 29622 RALEIGH, NC 27626-0622
(Revised August 2017) Form N-09
APPLICATION FOR CERTIFICATE OF AUTHORITY
FOR NONPROFIT CORPORATION
Page 2
10. (Check one of the following.)
a. _______The corporation has members.
b. _______The corporation does not have members.
11. Attached is a certificate of existence (or document of similar import), duly authenticated by the Secretary of State or other official
having custody of corporate records in the state or country of incorporation.
12. If the corporation is required to use a fictitious name in order to conduct affairs in this State, a copy of the resolution of its board
of directors, certified by its secretary, adopting the fictitious name is attached.
13. This application will be effective upon filing, unless a date and/or time is specified:____________________________________
This the ________ day of __________________ , 20_____.
___________________________________
Name of Corporation
___________________________________
Signature
___________________________________
Type or Print Name and Title
Notes:
1. Filing fee is $125.
2. This document must be filed with the Secretary of State.
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BUSINESS REGISTRATION DIVISION P. O. BOX 29622 RALEIGH, NC 27626-0622
(Revised August 2017) Form N-09
Instructions for filing
APPLICATION FOR CERTIFICATE OF AUTHORITY
FOR NONPROFIT CORPORATION
(Form N-09)
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 organization. If that name cannot be used in North Carolina, enter the name that it wishes to use in
North Carolina.
Item 2 Enter the state or country of incorporation.
Item 3 Enter the date of incorporation and the period of duration.
Item 4 Enter the complete street address of the corporation’s principal office.
Item 5 Enter the complete mailing address of the corporation’s principal office if different from the street address shown in
Item 4.
Item 6 Enter the complete street address of the corporation’s registered office and the county in which it is located.
Item 7 Enter the complete mailing address of the corporation’s registered office if different from the street address shown in
Item 6.
Item 8 Enter the name of the registered agent. The registered agent must be a North Carolina resident, an existing domestic
business or nonprofit corporation, or a foreign business or nonprofit corporation authorized to transact business or
conduct affairs in North Carolina.
Item 9 Enter the names, titles, and usual business addresses of the current officers of the corporation.
Item 10-12 See form.
Item 13 The document will be effective on the date and at the time of filing, unless a delayed date or an effective time (on the
day of filing) is specified. If a delayed effective date is specified without a time, the document will be effective at
11:59:59 p.m. Raleigh, North Carolina time on the day specified. If a delayed effective date is specified with a time,
the document will be effective on the day and at the time specified. A delayed effective date may be specified up to
and including the 90
th
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 presiding
officer of the board of directors or any officer of the corporation).
The name and title of the above-signed representative.
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