Fill this form COMPLETELY and send a Money Order or Check in the amount of $799.89 to:
Florida Certified Document Services
15476 NW 77 CT
MIAMI LAKES, FL 33016
First and Last Name: _______________________________________________________________________________________________
Phone Number: ___________________________________________________________________________________________________
REFERENCE Number: ______________________________________________________________________________________________
ONLY FILL THIS SECTION IF YOU ARE MAKING CHANGES:
Principal Address? _________________________________________________________________________________________________
Mailing Address? _________________________________________________________________________________________________
IF MAKING CHANGES TO ANY OF THE FOLLOWING, PLEASE INCLUDE COMPLETE NAME, ADDRESS, AND TITLE
Registered Agent? _________________________________________________________________________________________________
Adding Authorized Personal? _______________________________________________________________________________________
Removing Authorized Personal? _____________________________________________________________________________________
*** PLEASE FILL OUT AND SIGN BELOW *** ORDERS NOT SIGNED CAN NOT BE FULFILLED
Name of Individual Signing: _______________________________________________________________________________________
I agree to the terms & conditions and authorize this payment to Georgia Certified Document Services. I herby certify that the information above is correct and that I am authorized to conduct this transaction.
I hereby certify that the information indicated on this report or supplemental report is true and accurate and that my electronic signature shall have the same legal effect as if made under oath; that I am authorized to execute this report; I am aware that false information submitted in a document to the Department of State constitutes a third degree felony. I authorize Georgia Certified Document Services to submit this application on my behalf with the State of Georgia.
This signature must be that of the individual "signing" this document or be made with the full knowledge and permission of the individual, otherwise it constitutes forgery. The individual "signing" this document affirms that the facts stated herein are true.
NOTICE, a person may not:
Knowingly falsify or conceal a material fact,
Make a false, fictitious, or fraudulent statement or representation, or
Make or use any false document. Anyone violating these conditions is guilty of a third-degree felony and punishable by law.