DS-DE 41 Beach Residents Quality of Life •
REGISTERED AGENT OFFICE USE ONLY
STATEMENT OF APPOINTMENT
(Section 106.022, F.S.)
0 Original Appointment ❑ Change of Appointment
❑ Change of Mailing Address ❑ Change of Physical Address
Registered Agent and Office Information
Name Telephone
Mark Herron 850-567-4878
Street Address
2618 Centennial Place
City State Zip Code
Tallahassee FL 32308
Mailing Address
P.O. Box 1701
City State Zip Code
Tallahassee FL 32302-1701
I acct this ap intment and confirm that I am familiar with and accept the obligations of the position as set
forth ectio 1'6.022, F.S. I also understand that I may resign this appointment by executing a written
state ent ,•f re ig ation and filing it with the applicable filing officer.
6 March 2015
Signa re of egistered Agent Date
Former Registered Agent and Office Information (for changes only)
Name Telephone
Street Address
City State Zip Code
Committee or Organization Information
Name of Committee or Organization N _�
Beach Residents for Quality of Life
Street Address Telephone
2618 ntennial Place 850-567-4878
City State Zip Code
Tallaha see FL 32308
Sign. ure of I hairperson
Mark Herron 6 March 2015
Printed Name of Chairperson Date
Form DS-DE 41 (revised 6/11)