DS-DE 41 Miami Beach for All REGISTERED AGENT OFFICE USE ONLY
STATEMENT OF APPOINTMENT
(Section 106.022, F.S.)
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 accept is appoint ..nt and confirm that I am familiar with and accept the obligations of the position as set
forth in • -ction 10. '• , F.S. I also understand that I may resign this appointment by executing a written
stateme of re ••n . nd filing it with the applicable filing officer.
19 May 2015
Signature .f Regi ered 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 .
Miami Beach for All
Street Address Telephone
2618 Cen ennial Place 850-567-4878
City State Zip Code
Tallahass: • FL 32308
Ad '
Signatu of Ch irperson
Mark Herron 19 May 2015
Printed Name of Chairperson Date
Form DS-DE 41 (revised 6/11)
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