DS-DE 41 North Beach Neighbors Alliance de •
REGISTERED AGENT OFFICE USE ONLY
STATEMENT OF APPOINTMENT U
(Section 106.022, F.S.)
' ni6 JO I 9 N1 3: 2L
- --
itr Original Appointment 0 Change of Appointment
0 Change of Mailing Address El Change of Physical Address
Registered Agent and Office Information
Name Telephone
liViP KW c5S-G (,77 9Q/ 02_ 1-c7v
Street Address .--,
3 -5 o 0 c_ V 71- -- L__
City
a State Zip Coct
4464otim e_ -1--/ F6--
Mailing Address
City // State Zip Code
VIA-
I accept this appointment and confirm that I am familiar with and accept the obligations of the position as set
forth in Section 106.022, F.S. I also understand that I may resign this appointment by executing a written
statemeniif res', - 'on and filing it with the applicable filing officer.
/
Signature .f Registered 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
liir`I-Vk AC-e- --41 Ilielkib C.3 PY-(■/--- (e4/1--c-e-.
Street Address 93'37 0 Oc_okij /---- ct_j-e____ Tele /ptione "
67 -7 rif3C-clif
City 4/4-4/ State F .__ Zip Code
nk4 -166c3,--e_
"Eh Af 4101M
ig • ure of C airperson
ea-stir aJne5 %i 1 ' /9 16
Printed Name of Chairperson Date
Form DS-DE 41 (revised 6/11)